CHIPS FIRE Hazard Tree Felling Accident Facilitated Learning Analysis

Transcription

1 CHIPS FIRE Hazard Tree Felling Accident Facilitated Learning Analysis USDA Forest Service Pacific Southwest Region Plumas National Forest

2 Executive Summary On August at approximately 0945 hours, a limb fell from snag on the Plumas National Forest struck and injured a wildland firefighter faller. The faller s mission was to remove snags from a section of line on Division G of the Chips fire. The faller was a contracted professional timber faller, with 18 years of experience. The faller was in the process of falling a 61 inch diameter at breast height (DBH), 163 foot tall Ponderosa Pine buckskin tree when a limb approximately 5 inches in diameter and 5 feet in length fell approximately 63 feet and struck the back of the hardhat being worn by the faller. The faller had completed the undercut. He walked around the tree to retrieve his falling axe and began using it to remove a small portion of the wedge section still left in the undercut. He struck this small section four times and on the fifth strike a limb fell vertically striking the faller s hard hat. Emergency medical services were dispatched immediately. The faller lost consciousness for approximately 2-3 minutes. Emergency medical technicians (EMTs) at scene rendered care immediately removing the faller from the area and administered first aid. The faller regained consciousness and complained of head, jaw and hip pains. The medical evacuation of the patient took approximately 34 minutes from the time of the initial report until the patient was in Helicopter 407 and in route to the Enloe Medical Center in Chico CA. The faller received 18 staples in the back of his head and was released the same day. Several other firefighters witnessed the incident. The incident was also video-taped. A Facilitated Learning Analysis (FLA) was initiated on September 7, 2012 with the goal of identifying opportunities to strengthen the agency safety culture by identifying any lessons learned associated with the incidents and sharing those lessons with employees engaged in firefighting activities. The lessons learned through this process have applicability to any employee that routinely works in forested environments. The following report provides some lessons learned as well as recommendations that agency leadership should consider in an effort to minimize employee exposure to falling snags. More importantly, the recommendations in this report address several other issues related to the medical care of our employees injured in the line of duty as well as the extraction of those employees to the appropriate medical facilities. The objective is to focus on lessons learned that would enhance the overall safety and future management actions. Chips Fire Tree Felling FLA Page 2

3 Narrative Telling the Story The Chips fire started on July 29, 2012 on the Plumas National Forest northwest of Quincy, California. The cause is still undetermined. A type 1 IMT assumed command of the fire on August 3rd, On August 19, 2012 a plan was being implemented on Division G to burnout a piece of line west of Yellow Creek along a dozer line. Crews worked on prepping the piece of line all day on the 19 th in preparation for burnout operations to begin when conditions become favorable. The prep work included falling snags along the line that had been identified as hazardous. The large pine snag which was involved in this accident was identified as needing to be removed on the 19 th, however a decision was made to not remove the snag and instead dig line around it to try and keep fire from getting into it. On the evening of the 19 th and into the early morning of the 20 th, the line was burned out by night shift resources. Burnout operations were completed during night shift and the area was turned back over to day shift on the morning of the 20th. At the morning divisional breakout briefing, the plan for the operational period was to mop up 200 feet from the line. Engine crews would install a hose lay along the line to aid in the mop up and the 4 fallers would mitigate any additional hazard trees within the area. Four fallers were assigned to Division G and they spread themselves out along the area to give each other room to safely fall snags and provide minimum safe distances for falling operations. Faller 1 went to the area where the large snag was from the day before and found that the engine crews were already plumbing the hose on the line. Faller 1 met with Engine Boss 1 who tells him, If we are going to mop up 200 feet, that tree has got to come down at some point. Fire had gotten into the large pine snag and it was now smoking and smoldering from the top as well as around the base of the snag. Chips Fire Tree Felling FLA Page 3

4 Faller 1 made his way to the large pine snag, and began to size up the snag and prepare to fall it. Engine crew members on the line continued to install hose but many stopped to watch faller 1 cut down the large snag. Several crew members decided to video faller 1 cut down the tree which provided a record of the falling operation from beginning up to the time that the accident occurred. Faller 1 stated that when he sized up the tree, he identified that it had a heavy lean. He used his falling axe to sound the tree by striking it 3 times and determined that the snag was sound. Fire had made it into the snag and it was burning in the top and much of the top of the tree was smoking and smoldering. Faller 1 stated that he identified the limbs in the top as hazards, but believed that because of the heavy lean of the tree, anything that might come loose and fall down would miss his location and fall away from him working at the stump. CLICK HERE TO WATCH A VIDEO OF THE ACCIDENT Faller 1 began his falling operation by installing an undercut into the snag. When he finished cutting his undercut, Faller 1 walked around the back of the tree and used his axe to knock the wedge section out of the undercut. A small corner portion of the wedge section remained in the undercut and faller 1 struck this small corner trying to knock it out. While attempting to knock the small piece of the wedge section out of the undercut, a large limb approximately 5 feet long and 4 or 5 inches in diameter was dislodged from about 63 feet above ground and fell. The limb tumbled through other limbs causing it to rotate toward the faller and the limb struck the back of the hardhat being worn by the faller. The faller was knocked to the ground unconscious and the hardhat was knocked approximately 30 feet away. Chips Fire Tree Felling FLA Page 4

5 Personnel from the engine strike team notified the strike team leader that we have a faller down and responded to the faller to render aide. A quick evaluation of the situation was conducted by Emergency Medical personnel at which point, Engine Boss 2 made the call to move the faller to a safe location for further treatment and evaluation. This decision was made because the site where the accident occurred was highly dangerous both to the patient and to the caregivers. Faller 1 had regained consciousness by this time and was moved several hundred feet away, where additional medical treatment was administered. He was confused, complained of head and jaw pain and had a large laceration to the back of his head. The local engine strike team possessed 10 EMTs within their ranks. Emergency medical equipment was present on their engines, therefore, a back board, cervical collar and straps were quickly brought to the site and the faller was treated with full C-spine immobilizations and carried to an area where he could be evacuated by medevac helicopter. A few minutes after the faller was carried to the site known as the pumpkin site, the medevac helicopter arrived overhead. A rescuer was dropped via the helicopter hoist. The faller was place into an extrication basket and hoisted into the medevac helicopter. The rescuer then joined him in the helicopter and the faller was transported to an area medical facility for further evaluation. Total time between the initial accident notification and the patient extraction was 34 minutes. The Faller was evaluated at a local medical facility. He was diagnosed with a concussion and was released to rest and recover at home. An After Action Review was conducted on the line by the Division Supervisor with all personnel involved in the treatment and evacuation of the faller. Division supervisor stated that it was time to stop, take a break, and re-focus on the job at hand. Several personnel from the incident management team convened at the accident site to gather information and found evidence that the faller had been struck on the hardhat by a limb 5 inches in diameter and 5 feet long. The hard hat showed signs of being impacted by the limb, however, no additional damage was evident. The suspension system seemed to be intact and the shell showed no signs of cracks or splits. After documenting the accident sight, another faller finished felling the snag and operations in the area were allowed to continue. Chips Fire Tree Felling FLA Page 5

6 Chronology of Events August 20, Faller arrives at tree to be felled and begins his size up Faller is completing the undercut on the tree Strike Team Leader is notified that there has been a falling accident and a faller is down. EMT s from strike team are assisting faller at this time Strike team leader notifies Chips communications that a falling accident has occurred involving a head injury. Members of the strike team are providing Emergency Medical Care. Not able to make contact with Division Supervisor or Branch at this time Communication clears all command traffic for emergency traffic only Communications notifies Branch Director and Division Supervisor of the accident Strike Team leader requests Medevac helicopter respond Incident ambulance also requested to accident site The Medevac Helicopter is up on the Command frequency contacted, local ambulance is not able to respond because it is out of district Medevac helicopter is overhead and lowering rescuer to the evacuation site Local ambulance from another district is in route, ETA 8 minutes Faller has been loaded in Medevac helicopter Medevac helicopter in route to medical facility Medevac helicopter on the ground at medical facility. Chips Fire Tree Felling FLA Page 6

7 Lessons Learned The FLA Team facilitated dialogue with key players involved in this incident on the Chips Fire. During these conversations the participants shared lessons they learned from the accident and the response to the accident. The FLA team collected this information and summarized these lessons learned. Some of these lessons learned are applicable to not only the fire community, but also to the non-fire community as well. Pre-accident findings: The snag was identified as a possible hazard the day before the accident during preparations for the burn out operations. The decision was made to not fall the snag the day before, and instead protect the snag from the fire. The snag was prepped with a 5 to 6 foot line scrape and the small trees around the snag were cut with the fuel moved away from the snag. o Faller states, If I would have insisted on falling the snag the day before, it would not have had fire in the top of it, and it would have been safer. o Division Supervisor states, In the future, I will take out every snag which poses a risk before it is involved with fire. The medical evacuation plan had been discussed several days before the accident with resources on the fire. A previous accident on another fire had heightened everyone s awareness of the danger of snags. The medical evacuation plan had been discussed multiple times at various levels of management prior to the accident occurring. o The Strike Team Leader stated, We discussed the day s operations with everyone within the strike team each morning. We go through the IAP and this includes talking about the medical plan. o Strike Team Leader recommends, Not only should we review the medical evacuation plan, but he will always make sure he has a copy of the IAP with him at all times. If he had not had the IAP close at hand to refer to, he might not have been able to follow the plan so closely. Chips Fire Tree Felling FLA Page 7

8 Findings associated with the accident: The snag being felled was a very large pine snag with a heavy lean. The snag had become involved with fire from the burnout operation, and at the time of the accident had fire in the top half of the snag. The snag was located approximately 250 feet from the line and it was 165 feet tall. The plan for the day was to mop up 200 feet in from the line. This made it necessary to fall this snag so that the crews could complete their assignment safely. Faller did a complete and adequate size up of the tree. Faller identified the overhead limbs and fire as a hazard but felt with the heavy lean of the snag, any debris will fall straight down and miss him at the stump. Faller sounded the tree by striking it 3 times with his axe and found that the tree appeared to be solid with sound wood at the base. Note: no limbs or debris were dislodged during the sounding process. Faller began his operations by installing an undercut in the tree. He can be seen on the video looking up and watching the top of the tree many times as he creates the undercut. Faller completed his cuts for the undercut, but the wedge section was still in the tree. He walked around the back side of the tree and used his axe to knock the wedge section out of the undercut. He struck the tree 4 or 5 times with the axe to knock all the material out of the undercut. The limb broke free from the top section of the tree and bounced through other limbs on the tree. This caused the limb to not fall straight down but rather move laterally and fall down striking the faller on the hardhat. The faller was knocked unconscious onto the ground and the hard hat is knocked 30 feet away. The faller is a contracted professional timber faller, with 18 years of experience. The FLA team interviewed the faller and he provided the following lessons learned: o Do not assume that debris from the top of the tree will fall in a predictable manner. In any situation, the top of the tree must be watched at all times just in case something falls. o If a tree has a high likelihood of loose limbs or debris, try to not pound on the tree any more than necessary. The section of the wedge section remaining in the undercut could have been cut out which would have eliminated the need to knock it out with an axe. o Fall the tree when it is first identified. Do not wait. If the tree had been cut down the day before, the risk would have been reduced. Chips Fire Tree Felling FLA Page 8

9 After the accident Medical Evacuation Resources in the area of the falling accident were watching the falling operation from a safe distance and were able to immediately respond to assist the faller. Task Force Leader was notified immediately and the medical evacuation plan was implemented as planned. Communications Unit cleared all radio traffic for a medical emergency and notified the proper individuals. The medical evacuation plan had been developed by the incident management team and all resources were briefed on the plan and reviewed the plan daily on the line. o Division Supervisor and Strike Team Leader both noted that a lesson learned was to plan for and consider the What If? scenario. o Crews were knowledgeable of the chain of command and followed it throughout the incident within an incident. o Safety Officer monitored the medical evacuation from the communication unit. He stated that, the communication technician did a great job and followed the medical evacuation plan. He stayed calm and organized throughout the incident. Emergency medical care was provided by EMT s from the engine strike team. This strike team had 10 qualified EMT s within the strike team. o Several individuals within the strike team, as well as overhead and safety officers commented that it was good that these individuals possessed these skills, were trained and experienced in trauma incidents, and all the needed medical supplies were readily available on the strike team to quickly assess the patient and evacuate him to an area where he could be hoisted by the Medevac helicopter. Chips Fire Tree Felling FLA Page 9

10 Other Lessons Learned by Participants: Chain of command: The initial accident was reported to the Strike Team Leader. He was unable to communicate with the Division Supervisor or Branch Director via the radio, at which point he reported the incident to communications and began managing the incident within an incident. Communication was able to notify Branch Director and Division Supervisor via radio at which point they traveled to the accident sight. o Fire fighter from one of the engines stated, We briefed on the medical plan, but once the initial notification of the accident was made, chain of command took over and the incident followed chain of command until the end. o Division Supervisor stated, The incident within an incident was being successfully managed by resources on scene and additional overhead did not try to micro manage the accident. This helped keep chain of command clear and the management of the incident was able to run its course. Communications had been identified as an issue on this division for several shifts. Many dead areas existed in various parts of the division. It should be noted that Line medics were assigned to the division and were staged approximately 1 mile from the accident sight. They were unaware of the accident until the division supervisor drove by on his way to the accident and notified them. They had not heard any of the radio traffic. Span of Control Division Supervisor talked with the FLA team about the span of control on the division. Additional overhead was needed but was unavailable. This lead to the fallers not having a Felling Boss. In reviewing the IAP the only overhead in addition to the Division Supervisor was a Heavy Equipment Boss who was assigned with a Type 2 Dozer and the Strike Team Leader who was with the local engine strike team. o Division Supervisor recommends that contract fallers should have a qualified Felling Boss with them. This would provide an additional level of management to assist in identifying hazards and managing operations. Chips Fire Tree Felling FLA Page 10

11 FLA Team Findings and Recommendations Hazard Tree and Snag hazards Deteriorating forest health conditions nationwide have increased the number of hazard trees in the landscape. Wildland firefighters are facing an unfortunate confluence of events and conditions that are increasing the hazards that they face while suppressing wildland fires. Much like fire suppression itself, there is a conundrum involved in terms of risk management: the only way to reduce one hazard is to expose employees to another type of hazard. Chainsaws are used in fire suppression to eliminate or reduce hazards; but the use of a chainsaw always entails additional exposure to hazards, specifically the hazards faced by the sawyer when felling hazard trees. For example, fire crews are often not allowed to mop up a specific area on a fire until it has been snagged. This means that sawyers must enter the area and fell all the hazard trees before other employees can safely perform work there. This is pertinent because these hazards do not exist in a vacuum; they are one type of hazard that is often traded off against other hazards that would exist if the risks associated with mitigating hazard trees were not accepted. In February of 2012, a Programmatic Risk Assessment and Safety Assurance Evaluation For Chain Saw Use in Fire Suppression Operations was completed by the US Forest Service Branch of Risk Management and Human performance. Within this risk assessment, hazard trees and the risks associated with hazard trees was identified on several levels. Many of the suggested mitigation measures are already being implemented in the field; however, others are yet to be implemented and could serve to further reduce the level of risk faced by sawyers on wildland fires. For example, the programmatic risk assessment identified Being hit by aerial hazards falling from a tree being cut (EV1) as an environmental hazard. 7 possible mitigations were identified, one being Limit wedging and pounding activities (EV1M3). The faller also identified this as a lessons learned in his interview. Training specific to hazard trees and fire mitigation of hazard tree, which is also a mitigation measure from the risk assessment, may have provided the faller with additional knowledge which could have prevented the accident from occurring. The NWCG Incident Response Pocket Guide (IRPG) has a specific section referencing hazard tree on Page 20 (Gold Section). It states that hazard trees are one of the most common risks encountered on the fire line. They further identify situational awareness as an import step in mitigating this hazard and list hazard tree indicators to assist personnel in identifying hazardous trees. Chips Fire Tree Felling FLA Page 11

12 The tree involved in this accident met at least 4 or the 7 hazard tree indicators listed in the IRPG. Additionally, in the IRPG Hazard control methods are listed which include eliminating the hazard or avoiding the hazard. Another possible hazard control is to fireproof potential hazard trees to prevent ignition. A decision was made to fireproof this snag before the burnout operation. When making decisions on how to mitigate the hazard associated with a hazard tree in the wildland fire environment, current and future exposure to the hazard should be carefully considered. It should be considered what additional risk will personnel be exposed to if the fireproofing tactic is not successful and if it is decided to avoid the hazard, what ramifications will that have on other operations in the area of the hazard trees. It is recommended that hazard tree mitigation be considered as early as possible with all fire line operations and that they are considered in all aspects of operational risk assessment. If it is thought that the risk of hand falling hazard trees is too high, alternative methods should be considered. Chips Fire Tree Felling FLA Page 12

13 Incident within an Incident and Medical Evacuation Plan After the Dutch Creek Tree Felling Fatality in 2008, the Accident Review Board recommended the implementation of an incident within an incident plan and that each incident action plan (IAP) shall identify a procedure for medical emergency, rescue, and evacuation. These items were implemented by the Incident Management Team (IMT) assigned to the Chips Fire and Line personnel implemented these procedures during this accident. This plan and the procedures listed within this plan aided in the successful evacuation of the injured party. The time between the accident occurring and the patient being in route to a medical facility was approximately 34 minutes. All personnel involved in the development of this plan and the implementation of this plan should be commended on it success. It should be noted that daily briefings included discussion of the plan. Several individuals involved in this FLA noted that we have to continually be considering the What If? scenario and be prepared to implement the medical evacuation plan. Medics assigned to a specific division should be located close to any areas where the risk associated with the assignment are elevated, but should be mobile enough to move to another area if the situation changes or an accident occurs. Although it is not always possible, the FLA team recommends that medically trained personnel associated with fire line resources be identified by their immediate supervisor and that advanced medical supplies be staged as close to high risk areas as possible to facilitate medical evacuation should it be necessary. Chips Fire Tree Felling FLA Page 13

14 Communication Although not specifically identified as a contributing factor to this incident, communication issues were identified as an associated factor. Communication problems had been present throughout the division prior to the day of the accident. The Division Supervisor identified that on the day of the accident the medics assigned to the division were about a mile away from the accident sight and were unaware that an accident had occurred. Only when the Division Supervisor talked to the medics face to face were they made aware that an accident had occurred and that their assistance was needed. Because of the fact that the local engine strike team had qualified EMT s assigned to the engines, medical assessment and treatment of the injured faller was not delayed. However, this was a fortunate situation, which was not planned nor was it required by the incident that the strike team have qualified EMT s assigned to the engines. The FLA team would recommend that when it is known that communication dead zones exist within a division or area, all personnel assigned to the division should test communications when they arrive at their assigned location. LCES dictates that communication should be established prior to engaging the fire. Communications is a two way system and if a resource is not in communication then the situation must be resolved as soon as possible. Watchout situation #7 - No communication link with crewmembers/supervisors. Standard Fire Order #7 - Maintain prompt communications with your forces, your supervisor, and adjoining forces. These clearly state that communications should be maintained with all resources at all times. This is the responsibility of the supervisor and the subordinate alike. Communication should be verified anytime a resource moves or relocates. If you cannot establish communications with your supervisor try and establish communications with someone who can. Chips Fire Tree Felling FLA Page 14

15 Personal Protective Equipment The FLA team focused on the Personal Protective Equipment used by the faller during this incident. The actual hard hat was not available for our inspection, but pictures were available as well as statements from safety personnel from the Incident Management Team. Additionally, one member of the FLA team was at the accident scene immediately after the accident occurred and was able to personally inspect the hardhat worn by the faller. The hard hat showed scrapes and scratch marks associated with the impact from the limb strike. No physical defect or damage to the hard hat was observed. Although the suspension system inside the hardhat was pushed over to one side within the shell, all clips and suspension components seemed to be undamaged by the impact. The following pictures show the hardhat and the limb which struck the hardhat: Hardhat and Limb Hardhat with close-up of strike Hardhat Suspension pushed to left side Hardhat Suspension pushed to left side Chips Fire Tree Felling FLA Page 15

16 With the available information regarding the hardhat and the witness statements, it appears that the hardhat performed well and as it was designed. All information associated with the hardhat strike has been shared with the Missoula Technology and Development Center (MTDC) for further evaluation. It was discovered by the FLA team that the hardhat had been put back into service by the faller. We discussed this with the faller and recommended that the hardhat be taken out of service. The faller agreed to do this. It is recommended that when an accident involving a strike on a hardhat occurs, the hardhat is taken out of service and the hardhat is retained by the IMT and passed on to the appropriate officials. The ultimate goal should be to forward the hardhat to MTDC for further evaluation and analysis. This could greatly benefit the future development of Personal Protective Equipment for wildland fire fighters. In addition to the strike on the hardhat, the faller received a large laceration on the back of the head which took 18 staples to close at the hospital. There was no conclusive evidence to indicate if the laceration was caused by the branch, or by the suspension hardware of the hardhat. The question was asked by the FLA team of all participants interviewed in the FLA that from their perspective if they believed the laceration was caused by the limb or the hardhat. The majority of the participants, including the faller himself, believed that the laceration was caused by the suspension clips within the hardhat. It is recommended that MTDC continue to do further investigation into these suspension clips and continues to work with the manufacturer to ascertain if there is a problem with these clips and if a mitigation can be developed. Chips Fire Tree Felling FLA Page 16

17 Conclusion The Programmatic Risk Assessment and Safety Assurance Evaluation for Chain Saw Use in Fire Suppression Operations identified several mitigations which, if implemented, may have had a positive outcome on this accident. Minimize pounding on snags with overhead hazards Ensure management and supervisors practice risk informed decision making to eliminate unnecessary risk and exposure to all workers. Ensure sawyers practice on the ground risk management to avoid unnecessary exposure. Consider alternative methods to hand falling snags in high risk situations Develop training specifically for hazard tree mitigation on wildland fires. Ensure felling boss position is filled and that felling bosses are experienced and trained to identify and mitigate fire weakened hazard trees. Develop a national standard for qualifying contract fallers for wildland fire suppression It is recommended that the U.S. Forest Service accept the findings of the Programmatic Risk Assessment and support the implementation of all the proposed mitigation actions listed in the risk assessment. It was identified in this FLA that the faller, at the time of the accident, was not looking up at the top of the tree. We recommend that the SIMLIMB TOP DROP training and exercise be re-emphasized in annual refreshers, saw training, and hazard tree trainings. This training reinforces that looking up is the single most important thing a faller can do to avoid being injured by falling material from the top of any tree. The FLA team further recommends that the Felling Boss position be required when using contract fallers on wildland fires. This would increase awareness of special hazards associated with fire weakened snags. Professional timber fallers are a valuable asset; however, many are not experienced with the additional hazards associated with falling snags on wildland fires. This position can be invaluable for identifying hazard trees which need to be mitigated and providing adequate overhead to maintain span of control within an operation. Planning for an incident within an incident has been a key factor on many wildland fires. The incident action plan included this planning process which aided in a successful medical evacuation of the faller. Planning for the What If? is a key factor and should continue on all incidents in the future. Finally, the FLA team recommends that FLA s be initiated as soon as possible after an incident occurs. Timeliness increases the availability of key personnel to the FLA team, and facilitates the gathering of the facts and lessons learned for all personnel involved. The team would like to thank the Plumas National Forest for its cooperation and all those who participated openly in this FLA process. FLA Team Members Lee Mercer - Safety Officer - Plumas National Forest Tony McWilliams Saw Program Coordinator US Forest Service; Southwest Region Chips Fire Tree Felling FLA Page 17