Salt Fire August 29, 2011

USDA Forest Service Intermountain Region 4 Salmon-Challis National Forest

Remember, my life is in your hands out there. (dozer operator addressing firefighters).
Heavy Equipment Transport destroyed in burn-over.

I figured I might have survived without the shelter but probably not without injuries.

I got behind the safety shelter, then in a little bit I heard a voice say -Get in this truck!

Fire shelter blown into the trees after dozer operator escaped to safety.

Facilitated Learning Analysis of Entrapment, Shelter Deployment and Equipment Loss

Table of Contents: I. II. III. IV. V. VI. VII. Introduction.. Event Narrative.. Chronology of Events. Conditions.. Lessons Learned and Recommendations from FLA Participants. Lessons Learned from the FLA Teams Perspective.... Recommendations to the Delegating Official.. 3 4 11 12 13 16 18 19 30

Appendix A - Fire Behavior Appendix B Fire Shelter Personal Protective Equipment Report..

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I: Introduction

On August 29, 2011, at approximately 1800 hours a dozer operator and transport driver deployed a fire shelter during operations in support of the Salt Fire on the Salmon-Cobalt District of the Salmon-Challis National Forest in Idaho. At the same time, the tractor of a dozer transport was burned over and a lowboy trailer on a second transport was damaged. No injuries were sustained. A Facilitated Learning Analysis (FLA) was initiated on August 30, 2011. The goal of the FLA is to use this incident as an opportunity to strengthen the agency safety culture and increase awareness by identifying and sharing the lessons learned from this incident with others in the firefighting community. It is hoped that both firefighters and managers will use this report in a learning environment. This FLA has been made possible by the cooperation and support of the parties involved and the Salmon-Challis National Forest. The FLA team would like to express our sincere appreciation to all of the individuals who participated for their willingness and honesty in sharing their story. Vicinity Map

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II. Event Narrative The morning of August 28th, a dozer assigned to the Salt Fire is sent out to construct line along Division A to the west then continue around Division Z to the north. After unloading the dozer, the transport is backed into the trees along Forest Road 020 and the dozer is walked to the work location near Moyer Meadow (east side of Moyer Peak). The Transport Driver takes a fuel support truck to Moyer Meadow to stage for the shift. That evening, the Dozer Operator and Transport Driver return to town in the support truck to get fuel for the dozer.
Goodluck Cr. Woodtick Cr. Meadow

Moyer Meadow

On August 29th, the dozer operator and driver return to the work site near Moyer Meadow to resume line construction to the west and north in DIV Z. The Transport Driver has intermittent contact with his Dozer Operator by way of a walkie-talkie radio with a minimal transmission distance (primarily line of site). On DIV B the primary task is to use a handcrew to construct indirect line from the DIV A/B break back to the 020 road using Moyer Meadow as a staging area and safety zone. Sometime between 1100 and 1200 another dozer with Dozer Boss arrives at the junction near the location of the first transport. Their assignment is to construct a parking area large enough to safely park the two dozer transports that are now on-site. This second Transport Driver stays on-site and periodically moves both transports and a private vehicle belonging to the Dozer Operator, to allow the dozer to work. This location becomes known as Drop Point 3 (DP3). Another dozer was scheduled to assist with the construction but never arrived.

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At approximately 1400 hours, resources working in Division Zulu report increased fire behavior and they disengage to reassess their situation. Fire behavior on Division Zulu continues to be a problem and by 1600 hours, the Division Zulu Supervisor, Operations Section Chief, and Trainee order a recon of the fire. During the recon flight (approximately 1630 hours), they note that fire activity is increasing significantly all over the fire and has now backed down into the bottom of Goodluck Creek approximately one mile north of DP3. Anticipating that the fire is now positioned to move up Goodluck Cr., the decision is made to get the transports out to a safer location. A hotshot crew working on indirect line construction near the head of Woodtick Cr. is reassigned to look for opportunities to hold the fire west of Forest Road 020, by picking up spot fires if the fire behavior allows. Air-attack is monitoring fire movement but from their altitude the view of the bottom of Goodluck Cr. is obscured by the column. The recon flight lands in Moyer Meadow to drop off Operations and Trainee who then head to DP3 to oversee the movement of the transports. Shortly afterwards, Air Attack notices the fire in the bottom of Goodluck Cr. start to grow in intensity sometime between 1715 and 1720. At approximately 1730, the first dozer working in Division Z, contacts his Transport Driver who is still staged at Moyer Meadow and tells him about radio traffic on the divisions tactical channel concerning the urgent need to move the transport. The Dozer Operator tells him to locate a person with a fire radio and get further instructions. Within just a few minutes, the driver locates the Division Bravo Supervisor, who escorts him back to DP3 where he and the other driver are told to move the transports and the fuel support truck. A safety officer is assigned to lead them north on Forest Road 020 towards a spike camp at China Springs. Due to the urgency in removing the flammables in the fuel support truck from the area, one driver takes the fuel support truck and the other drives one of the transports. After driving about 1,000 yards down the road, the Safety Officer stops the vehicles and proceeds to scout ahead where he reports the fire has already crossed the road. With this escape route compromised, the Transport Driver begins swiftly backing the transport to DP3, but the narrow and winding road requires him to do a lot of maneuvering and because he does not have radio communication with the others behind him, he has to get out a couple of times to tell them to get out of his way. Meanwhile, the dozer is still working on enlarging DP3 and has cleared away debris from the entrance to a two-track road that has been identified by fireline leaders as an escape route to
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Squawboard meadow, approximately 350 yards south of DP3. Firefighters on Division Bravo understand that the situation is becoming critical and their options are narrowing. The Dozer Boss orders the dozer operator to clear a turnaround for the transport now trying to back down Forest Road 020 back to DP3. The dozer heads down the road to help but the Transport Driver stops the dozer operator from creating a turn around, convincing him that it would be much faster to continue backing the transport, so the group continues back to DP3. At DP3, several vehicles including the hotshot buggies, chase vehicles, and several others including Operations Section Chief-Planning, the Operations Chief-Field and Trainee arrive. The Superintendent of the hotshot crew is assigned to scout the meadow and determine if it can be used as a safety zone. He returns feeling confident the meadow is a good safety zone and reports this to fireline leadership. Upon arriving at DP3, the transport spins out in loose soil while attempting a steep angled backing maneuver in an effort to avoid hitting vehicles now scattered throughout DP3. The dozer attempts to push the transport further into the clearing using his blade to hook on the back end of the trailer. At about 1750, fireline leaders begin urgently directing resources to exit DP3 through the escape route to the safety zone at Squawboard meadow. At this time, the fire is approaching DP3 from the north and the escape route leading south to Moyer Meadow is also compromised.

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Seeing a wall of fire coming at him, the Transport Driver exits the now stranded transport, coming around the front of the vehicle, out of sight of the Dozer Operator. He is directed by the Dozer Boss to get his fire shelter and go to the center of DP3. On his way, the Operations Section Chief-Trainee directs him (using clear hand signals) to get in the dozer operators pickup and get it out of there. He follows hand signals to the escape route and out to Squawboard Meadow. The hotshot crew, now in the safety zone, prepares to burn out if necessary. [At this time fireline leaders report several individuals were taking photos and video which delayed their getting in their vehicles and heading to the escape route. These leaders expressed the desire to be the last one out of DP3, acknowledging the responsibility they bear for the safety of those working under them. Some individuals later reported part of their delay was due to not understanding there was a safety zone located at Squawboard Meadow. Some assumed DP3 was the safety zone while others remarked that they knew DP3 was an inadequate safety zone but believed they had no other options since the escape routes to China Springs (north) and Moyer Meadow (west) had been compromised and Squawboard Meadows was not known until moments before their escape.] At approximately 1752 (only two minutes after fireline leaders begin directing resources to the escape route) the fire front hits DP3. The Dozer Operator is still trying to move the transport when he realizes the transport driver is no longer there. He tries to move the dozer away from the edge of the clearing but the smoke and dust impair his vision and he fears he might hit a person or a vehicle so he stops the dozer where it is. With the fire approaching on the left side, he exits on the right side and retrieves his fire shelter from the right-side compartment. From the right side of the dozer, he cannot see any others vehicles in the immediate vicinity. He considers using the shelter, then second guesses himself but 8/29/2011 approx. 1752 decides if he is considering it, he hrs should just do it. After a moment,
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he notices the other Transport Driver crouching near the right front track of the dozer. The Driver tells him he has no fire shelter having left it in the transport, which is now unapproachable due to the heat. The two men believe they are alone at DP3. The Dozer Operator, not wanting to let the driver suffer without a fire shelter, shakes open his shelter and drapes it over the two of them down to their waists. While standing side-by-side, they get down on their knees and elbows. They both put their faces into the dirt; the Transport Driver cupping his hands around his face, while the Dozer Operator digs a hole and puts his face into it. The two find it difficult to breathe as dust and embers blow around them. After 1 to 2 minutes, they feel the heat upon them as the fire progresses around the perimeter of DP3. They subsequently decide they need to move to the front of the dozer to use the blade as a shield. The Dozer Boss, and Line Safety officer, believing they have no other options, remain at DP3 with their vehicles. When the Safety Officer left DP3 to escort the transport out, there was still debris in front of the two-track road to Squawboard Meadows, so he is not aware the dozer has cleared the debris or that it leads to a wet meadow. The Dozer Boss intends to remain with the dozer operator and removes his shelter from his line-gear and from its hard case and sets it within easy reach. The Safety Officer sees the fire shelter near the dozer blade, pulls his vehicle alongside the dozer, and directs the two men in the fire shelter get in. While still holding the fire shelter, the Dozer Operator, closes the vehicle door; most of the shelter is still hanging out of the vehicle. The Safety Officer and Dozer Boss move their vehicles around within the cleared area to avoid areas of heat. Most of the fire shelter eventually tears away from the vehicle. At one point, the Dozer Operator and Dozer Boss get out of the two vehicles and attempt to move the dozer away from a slash pile. They abandon the effort after realizing the key has been broken off in the ignition and return to the Dozer Bosses vehicle for shelter. At approximately 1800 hours, fireline leaders in the safety zone are becoming aware that the Safety Officer, Dozer Boss, Transport Driver and Dozer Operator are not in the safety zone and make contact via radio, receiving confirmation that all four are accounted for. The PlanningOperations and Operations-Trainee back a vehicle up the escape route to
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DP3 to assess the situation. They see headlights in the smoke and radio the Safety Officer to follow the sound of the honking horn. The Safety Officer rolls down the window but the roar of the fire around them makes it impossible for he or the Transport Driver to hear the horn. The Operations-Trainee directs the Safety Officer to the escape route using simple voice commands over the radio. The Dozer Boss and Dozer Operator follow in the second vehicle a few moments later. As they exit DP3, they notice the right front tire of the stranded transport is on fire. At ICP, leaders re-direct all aviation resources to provide support to the personnel in the safety zone. At 1930 hours, official word is received to disengage from all operations due to poor flying conditions (smoke and wind). After a while, a few people return to DP3 to assess the damage. At this time they report seeing the stranded transport tractor fully engulfed. They use an engine to suppress a fire on the lowboy trailer of the second transport and they drive two pickup trucks that had been left in the parking area to the safety zone at the meadow. These vehicles included a USFS pickup belonging to the Division Supervisor-Trainee, who had jumped in a vehicle with the Division Supervisor, and the fuel Support Truck. The Dozer Operator and his Transport Driver attempt to hotwire the dozer so it can be moved towards the center of DP3 away from unburned fuels. They are successful at getting the dozer started but cant keep the connection long enough to move it very far. At approximately 2130, after the Safety Officer has scouted the way, the remaining resources at Squawboard
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Meadow convoy out to the Spike Camp at China Springs. At 2200 the Operations Section ChiefTrainee leads an after action review (AAR).

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III. Chronology of Events on August 29th, 2011 Time (estimate) 0700 1100-1200 1330 Event Morning briefing at ICP. Operations delivers briefing to resources at spike camp Operation Section Chief-Trainee meets with Dozer Boss and assigns the task of creating a parking area for transports @ Drop Point 3 (DP3) Continue work in DP3 to facilitate parking for the 2 transports and smoothing surface. Discussion to enlarge area 4 times in size. Fire Activity begins to pick up. Division Zulu disengages to reassess. Transports moved off of road into DP3 Dozer Boss takes weather reading. RH is 17% Division Zulu experiencing continued increase in fire behavior. Operation Section Chief-Field and Trainee ordered recon flight from Moyer Meadow. At DP3, small open area was tied to thus enlarging the clearing. RH 16%. Operation Section Chief and trainee fly recon, fire behavior is increasing all over, especially on NE corner. Division Bravo Supervisor asks Recon to gauge the fires distance from DP3 in order to determine if there is time to get the transports moved. Decision made to get transports out. Line Safety Officer drives down from 099 road to recon out ahead of fire, observes ash blowing across 020 road and a big column of smoke building below the road. Dozer Boss notes that fire activity is increasing within sight of DP3; dozer continues work to increase the size of DP3. Operations Section Chief-Planning ties in with dozer boss at DP3 and starts collecting info on who is at the location. Transports cannot navigate road to south so decision is made to move transports north to China Spike. Line Safety Officer assigned to lead them out. Air Attack reports noticeable change in fire intensity in Goodluck Cr., indicating that it may have started to move up the drainage. Recon flight lands at Moyer Meadow and Operations Safety Chief and Trainee proceed directly to DP3. Division Bravo Supervisor and Dozer Boss told to get transports out. Dozer Operator calls his Transport Driver and tells him to find a person with a USFS radio because he is hearing that there is an urgent need to move the transports. Driver finds the Division Bravo Supervisor near Moyer Meadows who escorts him to DP3. Line Safety Officer leads the first transports out Forest Road 020 road toward China Springs. Line Safety Officer reports fire has crossed Forest Road 020 Transport begins to back toward DP3. Dozer clears debris from two-track leading to Squawboard Meadow and is assigned to cut turnaround for transport but is turned back. Fireline Leaders begin evacuation to Squawboard Meadow from DP3. Transport gets stuck backing into DP3. Transport driver exits the disabled transport and heads to Squawboard meadow as directed by Operations trainee using the Dozer Operators truck as his escape vehicle. Fire front hits DP3. One Transport Driver, Dozer Operator, Line Safety Officer and Dozer Boss are still at DP3. Dozer Operator and Transport Driver deploy shelter Page 11

1400 1500 1600

1630

1700 1715-1720

1725

1730

1731-1740

1749-1751

1752

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1805

1806 1810

1930 2100 2200

Dozer Operator and Transport Driver are gathered up by Line Safety Officer. As fire moves around DP3 both vehicles are repositioned to move away from heat. Dozer Operator and Dozer Boss attempt to move dozer away from unburned fuels, find the key broken off and get into the Dozer Bosses vehicle. Operation Section Chief-Planning is at Squawboard Meadow, everyone but 4 accounted for. Operations Section Chief Trainee confirms on the radio that the 4 are in their vehicles at DP3 but are unable to locate the escape route to the meadow due to poor visibility. Operations Sections Chief-Planning and Trainee return to DP3 to assist in their escape. Both vehicles are directed out of DP3 to Squawboard Meadows by Trainee. Upon exiting DP3, Transport Driver notices that the right front tire of one of the stranded transports is on fire. Everyone is out of DP3 at this time. Operations Section Chief-Planning walked back into DP3 to assess situation. Operation Section Chief-Trainee and Planning note that one transport is fully engulfed in flames. Personnel from Squawboard Meadow moved back into to DP3 and assess losses. Convoy of all resources drive to China Spike arriving at 2130 hours Resources at China Spike conduct After Action Review

The following URL will take you to a brief movie showing highlights of the afternoon of August 29th on the Salt Fire: http://www.myfirevideos.net/Default.aspx?VideoID=529 IV. Conditions Topography: The parking area DP-3, connected to Forest road 020, (44 58' 17" N, 114 10' 19" W, elevation 8,720 feet), is located on the north side of a saddle at the head of Goodluck Creek. Goodluck Creek drains directly to the north for 1.4 miles and then turns to the northwest an additional 0.8 miles to the confluence with Woodtick Creek at an elevation of 7,630 feet. The elevation difference between that confluence and the parking area is 1,090 feet. The slopes in Goodluck Creek vary from 21% in the bottom, 34% on the west facing aspect to 53% on the east aspect. Weather: The weather over the Salt Fire on Monday, August 29, 2011, was forecasted to be partly cloudy with a slight chance of showers and thunderstorms with maximum temperatures around 75 degrees and minimum RH around 15 to 20 percent. The 20-foot ridge top winds were predicted to be light from the southwest at 5 mph increasing and shifting west to northwest by the afternoon to 10 mph with gusts 20 mph, with the slope/valley winds light upslope 1 to 2 mph in the morning, becoming up-valley 2 to 4 mph by the afternoon. The Haines Index was forecasted to be 4 (low). Due to the poor Rh recoveries, the airmass was forecasted to rapidly warm in the early morning and be unstable by late morning. Monday, August 29, 2011, at 1311 hours, a Remote Automatic Weather Station (RAWS) was installed and operational at the VOR site (45 01' 14" N, 114 05' 05" W), 5.5 miles to the northeast of the parking Salt Fire Facilitated Learning Analysis Page 12

area (DP-3). The elevation of the RAWS was 9,250 feet, 530 feet higher than the parking area. The VOR site is fully exposed to wind from all directions. Average wind speeds ranged from 20-27 mph and the wind gusts from 31-44 mph between the hours of 1311 and 1811 hours. Wind direction varied between W to WSW. Temperatures and relative humidity during the same time period was 59 to 64 degrees F and 22 to 28%. Fuels: The fuels around parking area (DP-3) are characterized by a thick closed canopy forest. The fuels have a multi-layer vertical canopy profile and are composed of mostly lodgepole pine and subalpine fir (Exhibit 3 and 4). The Salmon-Challis N. F. has developed a Crown Fire Risk Mapping tool to predict crown fire potential. Goodluck Creek drainage and parking area (DP-3) had abundant ladder fuels and was mapped as Extreme Crown Fire Risk. The crown fire potential in this area has been compounded by the multiyear epidemic of Mountain Pine Beetle (MPB). The majority of the overstory and mid-canopy trees are lodgepole pine and MPB mortality ranges from 30 to 70%. In some areas red and dead lodgepole pine account for more than 50% of the forest overstory canopy. Crown fire transition fuels are abundant and the surface fuels are predominately an Anderson Fuel Model 10. Under these fuel and weather conditions, Fuel Model TU4 (J. Scott and R. Burgan, 2005) represents the fire behavior of these stands. V. Lessons Learned and Recommendations from the FLA Participants Individual Lessons Learned Trigger points should be based on the slowest moving piece of equipment Participants recognized that their sense of how much time they had to react was based on their personal experience in Figure out how much driving their vehicle or walking around the fire area. A better way to judge the time needed to react would time you need and have been to factor in the speed at which the then double it. transports could move. Take advantage of opportunities to share critical safety information The IHC Superintendent commented that while his crew members were in DP3 awaiting further instruction, he could have used that opportunity to have them go around and inform others in the area about the meadow which he had just confirmed was an adequate safety zone. Send scout vehicle out in advance of moving large transports Having the transport follow immediately behind the pilot car added another difficulty to the situation by blocking access/egress along the road and causing the driver to have to return to DP3 by backing up over mile on a narrow, winding road. Participants suggest that it is better to scout ahead and call back than to put the transport on the road if unsure of its ability to pass. Dont convey important info via cell phone Some participants felt that some information was being passed between line overhead and ICP that should have been transmitted via radio for the

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benefit of others on the fire (e.g. current status of the fire, location of potential safety zones, etc.) Consider the risk associated with driving a large number of vehicles through recently burned areas - A number of participants questioned the decision to convoy out, after dark, on a steep, winding and narrow road, through a recently burned area with fire weakened timber and uncertain road conditions. It was thought that if they had adequate supplies with them, maybe the safer choice could have been for them to stay in place at the meadow. People need to be getting to the safety zone when things are going bad and not taking video or pictures Fireline supervisors expressed frustration that several individuals were taking photos and video, not recognizing the serious nature of the situation and not understanding they were putting themselves and those around them at risk by not immediately getting in their vehicles and heading to the safety zone. It was time to swim to the boat, not wait until there was already blood in the water. If you have information that others need, you must make sure you deliver it. More than one person involved relayed that they did not have any idea that Squawboard Meadow was available as a safety zone. If lookouts cant see,(due to smoke) that should be a trigger point to get people out. Some participants mentioned that we rely a lot on air attack to be a lookout but if they cannot see due to smoke, this is a potential trigger because situational awareness is compromised. This We rely a lot on air attack to notion would apply to ground-based lookouts as well as aviation based. be a lookout, but when smoke Flag escape routes as soon as possible columns change, they are not Several individuals remarked that it would have helped the situation had they flagged the our best eye in the sky. two-track road to Squawboard Meadows immediately after it was discovered and/or when it was reopened by the dozer. Stress personal responsibility to know where you are on the fireline, where the nearest safety zone is, and how long it will take to get there Some fireline leaders who were informed after the incident that the Squawboard Meadows safety zone was unknown to numerous individuals, expressed concern that they were never questioned as to what LCES elements were in place if indeed these were unknown. It is important that weather/fire behavior forecasters deliver their forecasts in person whenever possible Line Operations delivered morning briefing to most resources as they were located at spike camp. It was felt by the weather and fire behavior forecasters that this scenario does not allow firefighters to ask clarifying questions about the forecasts or for forecasters to emphasize key information. Do not call a parking lot a safety zone Several participants recall hearing DP3 being referred to as either a safe area to park or something similar that indicated to them it was a safety zone. Others simply assumed that the dozer was engaged in clearing the area with the specific intent Salt Fire Facilitated Learning Analysis Page 14

of being a safety zone. Lesson learned is to take care not to refer to a drop point or other feature as a safety zone if it is not. Call it a parking area until it is approved as a safety zone. Agency Lessons Learned Equipment transports may need radios if they are positioned in or near the fire area. Participants recognized that not having radio communication with the transport drivers was a problem throughout the incident and amplified problems by slowing down the transfer of information to those individuals. Need to stress the reality of how big a safety zone needs to be in a crown fire Some participants felt that there may have been a misperception that the 1 acre clearing in DP3 may have been an adequate safety zone while others never considered this to be anything but a possible deployment zone. Several participants pointed out that the Incident Response Pocket Guide (NFES 1077) indicates an area of 12-40 acres is recommended given the type of fire behavior witnessed, thus DP3 should have never been considered to be a safety zone. Heavy Equipment operators should have headphones so they can hear the radio Participants commented that it is not uncommon for the equipment operator to lose situational awareness because of the noise and dust generated by the equipment. In dense timber such as was the case on I had a radio but I the Salt fire, the DOZB was not always visible either because doing so would have put him within the couldnt hear it. working zone of the dozer. It was advised that the dozer operators communication with the DOZB would be greatly improved if a headset or ear-bud were provided. Firefighting agencies, contractors, or other entities who operate fire equipment should avoid the use of color names in their equipment naming conventions - There was a point during the incident where supervisors were establishing accountability of resources and one supervisor relayed to another that they should have Green Engine #7 on scene, but the only engine visible at the scene was white in color, not green. This discrepancy was eventually resolved as the white engine on scene was in fact Green Engine #7 but in the heat of the moment there was concern that a resource had not been accounted for because of the use of a color name as part of the equipment identifier name. IMTs should evaluate how best to identify fireline equipment that has permanent identifiers visible on the equipment itself While establishing accountability of resources, there was additional confusion amongst the participants as to whether the engine at DP3 was Green Engine #7 which is the permanent insignia found on both doors of the vehicle, or was it Engine E-8 which was the ROSS equipment number assigned to that engine for this fire and was displayed with shoe polish in the upper right corner of the windshield. If it is possible to encourage a naming convention among participating agencies and contractors that maintains unique identifiers but eliminates the use of E numbers as identifiers on vehicles with existing identifiers, that would help fire personnel during high tempo operations. Of note however, the

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practice of matching the Dozer E-number with its corresponding transport was found to be very helpful in keeping track of machinery on the line (i.e. Dozer 5 is tied to Transport 5). Need parking lot management/discipline on fires so vehicles can enter and exit in an orderly fashion most of the time vehicles were being parked in an orderly fashion but at some point, a few vehicles were parked in DP3 in a way that hindered the ingress/egress of other vehicles. Participants commented that its always best to stay orderly in case you have to get going fast. It was noted however that because the dozer had not completed smoothing the parking surface and there were holes and debris present, it was not always feasible to park in an orderly fashion. Agency should consider a version of Standards for Survival targeted at contractors One of the contractors who had been through several Standards for Survival sessions previous to this incident commented that he always felt the firefighters were the target audience, not him. Up until now, he did not really grasp that he could really find himself in this sort of situation as a contractor whos just driving equipment around. His suggestion was to create a version targeted at non-firefighters with examples and cases that would resonate with that audience. VI. Lessons Learned and from the FLA Teams Perspective Do not hesitate in using your shelter if you believe you may need it - There remains a stigma associated with pulling a fire shelter. The individuals who used the shelter heard negative comments generally indicating there would be trouble for all involved because a shelter was used. This cultural issue has great potential to cause individuals to delay using the fire shelter until it is too late. The SOFR and DOZB, both very experienced firefighters, indicated they were checking I heard Now youve to make sure their shelters were readily accessible popped your shelter, during this incident indicating that there was indeed eminent danger involved with this situation. Several youre going to have participants remarked and the FLA team agrees, that given the information they had at the time, the dozer to answer for it! operator and transport driver acted appropriately by deploying the one shelter they had available as soon as they felt that it was needed. Consider the mobility of the resource when establishing LCES - Multiple escape routes and safety zones were available for all resources except for the transport vehicles which due to their size, could not negotiate the road to Moyer Meadows and therefore only had one escape route (020 road back to China Spike). A good lesson may be to realize that LCES will apply differently to various resources depending on their mobility so plan accordingly. Scan for hidden hazards, dont get focused on the most obvious - The preoccupation on DIV B was centered around the primary task involving the handcrew constructing indirect line above Woodtick Cr. Multiple lookouts and supervisors were engaged in directing this activity. This may have distracted attention from the secondary operation which was to construct a parking area at DP3 for the two equipment transports. A lesson to take away is to study the primary source of your problems but dont lock in on it, look around for other hazards as well. Salt Fire Facilitated Learning Analysis Page 16

Simplify when you have to but take the time to study fire behavior more closely when you can There are rules of thumb that experienced firefighters commonly use that allow us to react quickly and correctly to most situations. In rare instances however, these same simplifications may shield us from seeing subtle yet important clues to predicting the fires next move. On this fire, several very capable and experienced firefighters commented that they did not really predict the fire would come towards DP3 in such an aggressive manner, expecting more of a moderate push to the east-northeast based on the weather forecast and what they witnessed the fire do over the previous shifts or that it would move through Woodtick Cr. before it would take out Goodluck Cr. The lesson learned is that we have to trust our quick estimates when were in a compressed time wedge and minutes count, but we need to be suspicious of them also. Trust your instincts, youll be right most of the time, but be aware of their limitations and mix in some critical thinking (what am I missing?) when the time allows. Some examples of some simplifications that we use may include: o We often assume that todays fire behavior will either be worse, better, or the same as it was yesterday depending on if the weather forecast is worse, better, or the same. What we may be missing is whether the fire is now positioned in a new fuel type or in a location where the alignments of wind and slope have changed from previous days. o We often simplify our estimate of fire spread direction by assuming it will generally move in the direction of the prevailing wind. This fire demonstrated that terrain influences on wind flow as well as presence of highly volatile fuels will have a dramatic influence on the rate and direction of spread. o With unburned fuel between us and the fire, we tend to be on high alert at short to intermediate distance from the fires edge. At some point however, as we move away from the threat, we begin to feel more and more comfortable that we will have adequate time to detect danger and react accordingly. This fire covered over a mile in less than 1 hour and allowed only about 30 minutes to react from the time it started its run to when the first escape route was compromised. In these fuel types that are highly susceptible to crown fire, fire behavior forecasts may want to describe potential crown fire rate of spread as well as ground fire On this fire, model runs were made that accurately predicted behavior for ground fire movement, however the fire that impacted DP3 was a sustained crown fire run with a rapid rate of spread (over 1 mile per hour). In similar fuel types (dense timber, low crown heights, drought or bug kill, etc.) FBANs may want to consider including predictions for crown fire ROS in their briefings and planning products. While we may not predict precisely if a fire will transition to a crown fire, we can provide firefighters with an estimate of how fast it will be traveling if they witness crown fire so they can better calculate their escape options. Firefighting community generally displays hallmarks of a High Reliability Organization o This IMT maintained high sensitivity to operations by adjusting planning schedules to accommodate a high tempo operation. o The personnel on this incident did a good job of deferring to expertise. Those with the best knowledge and abilities to accomplish critical tasks or make key decisions were Salt Fire Facilitated Learning Analysis Page 17

given responsibility for those tasks and/or decisions no matter what their position in the organizational hierarchy. o All personnel on this incident, especially the fire-line leadership, were especially resilient. They were quick to adjust tactics when new information was received that negated not just earlier plans, but their entire perception of the situation. Rather than side compartments, fire shelters should be located in the cab of the dozer or better yet, attached to the dozer operators belt or chest harness The dozer operator on this incident made a conscious choice to exit on the side opposite the oncoming fire. Had his shelter not been in the compartment on that side, he may not have reached it at all. Equipment operators and drivers should consider using flame resistant flight gloves - Since leather work gloves are not suited for dexterity which is necessary to operate machinery, it may be advisable for operators to wear gloves that allow for comfortable movement yet still offer protection in an emergency. Alternatively, keeping work gloves on a belt loop or with the shelter may be a good idea. VII. Recommendations to Delegating Official Request the issuance of a Fire Behavior Alert to bring attention to the critical fuel conditions found in the mountain pine beetle infected areas of the Salmon-Challis and surrounding forests; include reference to Jolly et. al 2011 Request staff to pursue revision of Pre-Use Inspection checklist for equipment inspectors to ensure contractors are compliant with contract requirements including PPE (OF-296) Until checklist forms can be updated, remind contract inspectors that all contractors should have the new-generation fire shelters and be trained in its use.

Team Members Stephaney Church, R4, Boise National Forest, Mountain Home RD, District Ranger (Team Leader) Frankie Romero, R4, Payette National Forest, McCall Smokejumper Base Manager Ivan Erskine, R4, Regional Office, Acting Regional Operations Specialist LeeAnn Evans, R4, Regional Office, Incident Business Management Specialist Denise Camper, R4, Salmon-Challis National Forest, Forest Safety Officer Anthony Petrilli, R1, Missoula Technology and Development Center, Equipment Specialist

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APPENDIX A Topography, Fuels, Fire Weather, and Fire Behavior Narrative Salt Fire Salmon-Challis National Forest August 29, 2011 Topography: The parking area DP3, connected to Forest road 020, (44 58' 17" N, 114 10' 19" W, elevation 8,720 feet), is located on the north side of a saddle at the head of Goodluck Creek. Goodluck Creek drains directly to the north of the parking area for 1.4 miles and then turns to the northwest an additional 0.8 miles to the confluence with Woodtick Creek at an elevation of 7,630 feet. The elevation difference between that confluence and the parking area is 1,090 feet. The slopes in Goodluck Creek vary from 21% in the bottom, 34% on the west aspect to 53% on the east aspect (Exhibit 1). Exhibit 1

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Fuels: The fuels in the Goodluck Creek drainage and around parking area (DP3) are characterized by a thick closed canopy forest that have a multi-layer vertical canopy profile composed of mostly lodgepole pine and subalpine fir (Exhibits 2, 3, and 4). The lodgepole pine, which is the majority of the overstory and mid-canopy trees, have been hit by multi-year epidemics of Mountain Pine Beetle with mortality ranging from 30 to 70%. The stands are similar to conditions described in the paper MOUNTAIN PINE BEETLE-INDUCED CHANGES IN LODGEPOLE PINE NEEDLE FLAMMABILITY, Dr. Matt Jolly, Dr. Russ Parsons, Ann Hadlow and Greg Cohn, US Forest Service, RMRS, Fire Sciences Laboratory, Missoula, MT, Mountain Pine Beetle Forum, 04 May 2011. The lodgepole pine, which is the majority of the overstory and midcanopy trees, have been hit by multi-year epidemics of Mountain Pine Beetle with mortality ranging from 30 to 70% and have a mixture of live green, attacked, yellow, red, and standing dead with no needles. The trees in the stands of mature lodgepole pine and sub alpine fir surrounding the parking area and in Goodluck Creek are generally 40 to 60 feet tall. Exhibit 2

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Exhibit 3

Exhibit 4

Photo looking to the east from the ridge above Woodtick Creek. The next drainage east of Woodtick Creek is Goodluck Creek. Salt Fire Facilitated Learning Analysis Page 21

Due to the wet cool weather patterned experienced during the spring and early summer of 2011, fuel moisture conditions on the Salmon-Challis National Forest have not been considered to be in drought conditions. However, the Energy Release Component values in Central Idaho were above the 90th percentile on August 29, 2011, and were definitely on an upward trend. On September 6, 2011, the ERCs approached the 97th percentile and historic highs (Exhibit 5). During the first week of September in the area of the Salt Fire, a small sampling of needles from lodgepole pine that were green attacked showed the foliar moistures was between 90-100%. Exhibit 5

Fire Weather: The weather over the Salt Fire on Monday, August 29, 2011, was forecasted to be partly cloudy with a slight chance of showers and thunderstorms with maximum temperatures around 75 degrees and minimum RH around 15 to 20 percent. The 20-foot ridge top winds were predicted to be light from the southwest at 5 mph increasing and shifting west to northwest by the afternoon to 10 mph with gusts 20 mph, with the slope/valley winds light upslope 1 to 2 mph in the morning, becoming upvalley 2 to 4 mph by the afternoon. The Haines Index was forecasted to be a 4. Due to the poor Rh recoveries, the airmass was forecasted to rapidly warm in the early morning and be unstable by late morning (Exhibit 6).

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Exhibit 6

INCIDENT Weather Forecast

FORECAST NO:

NAME OF FIRE:

Salt Fire

PREDICTION FOR:

Day SHIFT

UNIT:

Salmon Challis NF

SHIFT DATE:

Aug 29th 2011

SIGNED: Incident Meteorologist

TIME AND DATE: FORECAST ISSUED: Aug 28th 2011 2000 hrs ------------------------------------------------------------------------------------------------------------------------WEATHER DISCUSSION: An upper low over central Oregon on Sunday will shift over the Idaho Panhandle through the day Monday. This will help bring a mention of showers and thunderstorms over the fire area. Slightly cooler conditions expected. Winds over the ridges are expected to shift from southwest in the early morning hours to west to northwest by the afternoon as the low shifts into Montana. A strong cold front will push into the Pacific Northwest on Tuesday and slowly push into the fire area by Wednesday afternoon. Strong gusty winds over 30 mph are expected both Tuesday and Wednesday. ------------------------------------------------------------------------------------------------------------------------WEATHER FORECAST:

WEATHER: Partly cloudy with a slight chance of showers and thunderstorms. TEMPERATURES: Max temperature around 75. HUMIDITY: Min RH around 15 to 20 percent. 20 FT WINDS: RIDGETOP - Light Southwest wind to 5 mph increasing and shifting west to northwest by the afternoon to 10 mph with gusts 20 mph. SLOPE/VALLEY - Light upslope 1 to 2 mph in the morningbecoming upvalley 2 to 4 mph by the afternoon. HAINES INDEX: 4 STABILITY/INVERSION: Due to the poor Rh recoveries expectedairmass will rapidly warm in the early Morning

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and be unstable by late morning. ------------------------------------------------------------------------------------------------------------------------OUTLOOK FOR Tuesdays day shift: Mostly sunny in the morningpartly cloudy by the afternoon. High around 80 with southwest winds over the ridges increase to 10 to 15 mph with gusts to 25 mph. HAINES 5 expected. ------------------------------------------------------------------------------------------------------------------------OUTLOOK FOR Wednesday: Partly cloudy with a slight chance of showers and thunderstorms. Highs in the 70s with winds over the ridges southwest to 15 mph with gusts to 30 mph. Haines 4 expected. -----------------------------------------------------------------------------------------------------------------------------Extended Forecast: Thursday and FridayCold frontal passage expected Wednesday night with temperatures dropping about 10 to 15 degrees. Winds decreasing and shifting west to northwest.

On Monday, August 29, 2011, a Remote Automatic Weather Station (RAWS) was installed and operational at 1311 hours at the VOR site (45 01' 14" N, 114 05' 05" W), 5.5 miles to the northeast of the parking area DP3. The elevation of the RAWS was 9,250 feet, 530 feet higher than the parking area. The VOR site is fully exposed to wind from all directions. Average eye level wind speeds recorded between 1311 and 1811 hours, ranged from 20-27 mph and the wind gusts from 31-44 mph. Wind direction was predominately from the west. Temperatures and relative humidity during the same period was 59 to 64 degrees F and 22 to 28% respectively (Exhibit 7). Exhibit 7
Past Weather Conditions for TT031 Observations prior to selected time: August 29, 2011 - 23:59 MDT Weather Conditions at August 29, 2011 - 23:11 MDT 23:11 Temperature Dew Point Relative Humidity Wind Speed Wind Gust Solar Radiation Fuel Temperature 10 hr Fuel Moisture 52.0 F 39.8 F 63% 24 Hour Max 24 Hour Min 64.0 at 17:11 52.0 at 22:11 39.8 at 23:11 20.2 at 15:11 63 at 23:11 22 at 14:11 11 at 23:11 18 at 23:11

11 mph from WNW 27 at 14:11 18 mph 0.0 W/m*m 50.0 F 6 gm 44 at 15:11

842.0 at 13:11 0.0 at 22:11 72.0 at 17:11 50.0 at 23:11 6 at 23:11 5 at 18:11

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Battery voltage

12.70 volt

14.00 at 14:11 12.70 at 22:11

Precipitation accumulated since midnight: -, in 24 hours: -

Tabular Listing: August 28, 2011 - 22:59 through August 29, 2011 - 23:59 MDT Time(MDT) Temperature Dew Relative Wind Wind Wind Quality Solar Precipitation Fuel 10 hr Fuel Battery

Point Humidity Speed Gust Direction check Radiation accumulated Temperature Moisture voltage F 23:11 22:11 21:11 20:11 19:11 18:11 17:11 16:11 15:11 14:11 13:11 52.0 52.0 54.0 57.0 61.0 63.0 64.0 63.0 59.0 60.0 61.0 F 39.8 39.0 39.1 37.5 36.5 29.4 27.5 24.6 20.2 21.1 24.9 % 63 61 57 48 40 28 25 23 22 22 25 mph mph 11 14 16 16 16 19 18 21 20 27 21 18 20 21 23 26 32 31 37 44 38 35 WNW Caution WNW Caution WNW Caution WNW Caution WNW Caution W W Caution Caution W/m*m 0.0 0.0 2.0 64.0 261.0 482.0 667.0 490.0 450.0 763.0 842.0 in 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 F 50.0 51.0 53.0 58.0 64.0 70.0 72.0 69.0 63.0 67.0 71.0 gm 6 6 6 5 5 5 5 5 5 6 6 volt 12.70 12.70 12.80 12.90 13.20 13.60 13.40 13.50 14.00 14.00 13.50

WSW Caution W W WSW Caution Caution N/A

Fire Behavior: The Salmon-Challis N. F. has developed a GIS layer showing the Crown Fire Risk to predict crown fire potential for the entire forest. Woodtick and Goodluck Creek drainages and parking area (DP3) had abundant ladder fuels and are mapped as Extreme Crown Fire Risk (Exhibit 8).

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Exhibit 8

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Crown fire transition fuels are abundant and the surface fuels are predominately an Anderson Fuel Model 10. Under these fuel and weather conditions, Fuel Model TU4 (J. Scott and R. Burgan, 2005) closely models the crown fire spread rates observed in these stands. By early afternoon on August 29, 2011, the fire had become well established in the bottom of Goodluck Creek. A major crown fire run started at approximately 1700 hour in a south-southeast direction toward the parking area DP3. Flame heights were in excess of 100-150 feet at the parking area and much higher than that in Goodluck Creek (Video Link of - crown fire in Goodluck Creek). The crown fire rate of spread was approximately 70-80 ch/hr. When the fire front hit the parking area at approximately 1752 hours, is was described as a Glancing blow by one of the individuals in the parking area (Exhibit 9). Exhibit 9

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Predicted Fire Behavior for the operational period Monday, August 29, 2011 (Exhibit 10). Exhibit 10

FIRE BEHAVIOR FORECAST

FORECAST NUMBER: 2 FIRE NAME: Salt Fire DATE ISSUED: 28 August 2011 UNIT: Salmon-Challis National Forest TYPE OF FIRE: Wildfire OPERATIONAL PERIOD: 29 August 2011 TIME ISSUED: 2000 SIGNED: FBAN

INPUTS
WEATHER SUMMARY: Partly cloudy conditions with a slight chance of showers and thunderstorms will moderate the drying of fuels. With slightly higher forecasted RHs (15 to 20%), lower temperature (75 degrees), and winds (5-10 W-NW G 20), HAINES INDEX of 4, expect a day of slightly less intense fire behavior from yesterday, mostly where shading from the sun occurs with the predicted minimal cloud cover. Expect activity to rapidly increase if the cloud cover breaks or fails to develop during the burning period. FUELS: th ERCs for the area continue to approach the 90 percentile. Currently at 86%. The ERC trend historically at this time of the year is decreasing. The high degree of bug kill in the area is effecting the fuels in a manner that would normally be represented by drought conditions. This is an indication that fuels are much drier and available to burn than normally at this time in the season. GENERAL: Fire behavior should be less active than yesterday. Fire behavior will include creeping, single tree and group tree torching, short range spotting and moderate runs in continuous fuels where they align with slope and/or wind. Movement will continue to be mostly in thick conifer timber stands with down and dead components.

The Burning period started early yesterday at about 1000 hrs almost as soon as the sun shone on the fire. For today expect the burning period to be similar. Expect the most intense burning from 1400 to 1600 hrs.

Fuel Model

Ground Fire ROS (ch/hr) Head Backing 3

Ground Fire Flame Length (ft) Head 10 Backing 3

PIG

Spot_Dist

TU4 Timber

20

63%

.2 mile

Fire behavior predictions are for the hottest and driest period of the day.

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SPECIFIC: DIV A As the winds shift to the West and Northwest with the frontal passage the fire has the potential to push or hook your area. AIR OPERATIONS: Expect gusty conditions near cumulus buildups in the afternoon.

SAFETY
Burning bases in the bottoms of multitude snags will continue be a hazard throughout the fire area.

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APPENDIX C Salt Fire Entrapment/Fire Shelter Deployment Personal Protection Equipment Report Fire Shelter Old-style Fire Shelter Date of Mfg: Nov/1999 The fire shelter was found on the east side of the parking area lying next to a number of burned trees. The shelter received direct flame contact much of the aluminum foil had delaminated from the fiberglass cloth. The fiberglass cloth was brittle due to the flame contact and high temperatures. One fire shelter sod cloth was torn away from the shelter and was found in the middle of the parking area. The sod cloth showed no signs of heat. The old-style shelter hard plastic liner and PVC bag were found next to the right side of the dozer. Neither the hard plastic liner nor the PVC bag show signs of melting; melting occurs at about 300 degrees F. The blue nylon carrying case of a New Generation fire shelter was found in the compartment on the right side of the dozer. It was reported that when the dozer operator and transport driver were picked up, it appeared the shelter was still intact. However, the shelter was shut in the door of the vehicle and was torn due to driving within the parking area.

Parking Area/Deployment Site Size 1.1 acre parking area was mostly void of burnable fuel. The lack of burnable fuel and the relatively large size of the parking area proved sufficient to prevent direct flame contact to the deployment site. Except for the south-west side of the parking area, the fire burned in a high intensity crown fire. During the entrapment, the DOZB was in his vehicle. He felt the need to remove his fire shelter from its pack and have it ready for a possible deployment. He thought that he would deploy the fire shelter inside the vehicle, but be prepared to get out and deploy his shelter on the ground. During the entrapment, the SOFR was in his vehicle. He needed to strategically move his vehicle in order to avoid heat and flames. The vehicles rear driver side tail light received enough heat that the plastic become soft. He felt the need to be prepared to deploy his fire shelter and was mentally prepared to do so. Fire Shelter Experience The dozer operator and transport driver deployed the shelter over both of them as much as they could. They both emphasized the need to protect their airway.
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By deploying the shelter on the side of the dozer away from the initial direction of the fire, the firefighters received added protection from the dozer blocking radiant heat. When the fire progressed around the parking area, they decided to reposition and move to the front side of the dozer, in order to keep the dozer between them and the hottest part of the fire. While under the shelter, the transport driver felt that there was no oxygen and that he could not draw a breath. While under the shelter, the dozer operator felt the need to use his asthma inhaler.

Reminders/Recommendations Fire Shelters According to the 2011 Interagency Standards for Fire and Aviation Operations (The Red Book), the NEW GENERATION FIRE SHELTER is required for ALL firefighters, including equipment contractors. ALL old-style fire shelters are to be taken out of service. All contract inspectors shall ensure that all contractors have New Generation Fire Shelters for all personnel. If fire-going personnel are found to be carrying an old-style fire shelter, the person shall be removed from the fire area until the firefighter can obtain a New Generation Fire Shelter and receive training on the proper use of it. Fire shelters are to be easily accessible; inside a compartment on the side of a dozer is not an easily accessible location. If not attached to a dozer operators belt or harness, fire shelters should be located in the cab of the dozer. Gloves Recommended policy for equipment operators and drivers Since work gloves are not designed for fine motor skills, equipment operators and drivers should be able to wear flame resistant flight gloves during fire operations. Reminder It is very important that firefighters keep gloves on during an entrapment. Taking a glove off (then consequently losing it), is not a good idea. Firefighters put themselves in greater risk of injury if they are not wearing gloves.

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