Water Flowing Uphill Double Medevac: Two Firefighters Hit by Falling Branch. Facilitated Learning Analysis 2018

Transcription

1 Water Flowing Uphill Double Medevac: Two Firefighters Hit by Falling Branch Facilitated Learning Analysis 2018

2 The primary goal of this review is to understand the decisions and actions that were made based on the conditions that existed when they were made, and to identify and share lessons learned within the Interagency Fire Community. NARRATIVE PAGE 3 TIMELINE PAGE 6 LEARNING SHARED PAGE 10 DISCUSSION QUESTIONS AND ACTION ITEMS PAGE 12 FLA TEAM MEMBERS PAGE 14 Special thanks to the staff at the Wildland Fire Lessons Learned Center for support and input on the product development, to the Zigzag Hotshots, and to all of the personnel that contributed interviews, photographs and other content for this document. 2

3 INTRODUCTION CRACK! POP! Joel knew that sound and he knew if he looked up he would get hit right in the face. By the look on Memo s face (his partner), he knew he was going to be hit. A nine foot long branch-- 9 inches in diameter-- has just released from high up in the green trees canopy. Not knowing what direction to move, Joel shrugged his shoulders and braced for impact. Memo tried to push Joel out of the way, but there was no time. The limb struck Joel on the left side of the hard hat at an angle smearing the hard hat off his head. The branch also hit Memo hard on the back, knocking him to the ground. Two firefighters are now hurt. Are the injuries serious? How will they get out of there? Quick decisions were made short haul? Set up a rope raise? Or take 60 hotshots and caterpillar the injured out? The swift medical assessment and ground evacuation that was described as water flowing uphill soon followed. The story here is a description of several hotshot crews engaged in direct attack on a fire in extreme terrain with numerous snags, and steep slopes with rocks rolling down the hill like a bowling alley. Why were they exposed to such risk? Why were they even there? What happened? Did someone mess up cutting a tree? Did someone walk under a bucket drop? Did they lose situational awareness? When choosing to initiate a Facilitated Learning Analysis (FLA) for an unintended outcome, there is an expectation of learning. Using the unintended outcome as a diving board for rich learning opportunities there is somehow a hope that these lessons can prevent similar accidents from happening in the future. But what do we learn when there is no glaring mistake made? No Human Error that caused the accident? After a thorough review of this incident, the FLA team has come to a potentially confounding conclusion: That in the case of the San Antonio Fire accident, Line Officers, IMT members and on the ground firefighters did just about everything right. But wait, firefighters got hurt really bad WHY? FIRE SITUATION On June 13 th, 2018, a storm passed over the high mountains of Jemez in northern New Mexico. Dry lightning easily ignited a wildfire in the critically dry fuels in Valles Caldera National Preserve hour fuels were in the single digits and ERC s consistently above the 97 th percentile. Fire danger values were higher than when the nearby Los Conchas fire of 2011 that grew 40,000 acres in one day. The area had been in the worst drought in history and the relatively new national park site at Valles Caldera and the adjacent Santa Fe National Forest had been in severity for 2 months. The smoke report was called in to Santa Fe dispatch on June 14 th and the new San Antonio fire estimated at ¼ acre. The fire was burning at ,000 feet in a mixed conifer forest type with heavy fuel loading and grew rapidly to several hundred acres. These were not the conditions to consider managing for resource benefit this was going to be a full suppression fire. Being pushed by a strong SW wind, the fire was growing quickly and closer to the USFS boundary to the north and directly toward an area that had been identified as a critical value at risk. The Cañones watershed was 3

4 described by US Forest Service AFMO as decadent with a lot of snags, heavy dead and down fuels, with steep and rocky terrain. This is a stand-replacement fire regime if fire would get in there it would be a moonscape with devastating downstream impacts including considerable silting of a vital water source once the monsoonal flooding started. Later that same day a local zone Type 3 Incident Management Team (IMT3) was ordered and took over the fire at 20:00 the following day, June 15th. As the fire was close to the NPS/FS boundary, a dual Delegation of Authority signed by the Superintendent of Valles Caldera National Preserve and the Forest Supervisor of Santa Fe National Forest --was given to the team. DIRECT OR INDIRECT? ALL OPTIONS CARRY RISK SO WHICH IS BEST? After scouting the area, the Division Supervisors (DIVS) and the Superintendents of the Zigzag and Prineville Interagency Hotshot Crews (IHCs) discussed going direct or indirect, including the probability of success, the amount of work required, the exposure to and mitigations of the risk, the weather and its effects on the fuels and fire behavior. The best option for going INDIRECT would have included cutting approximately a mile of handline downhill with a foot elevation drop through heavy mixed conifer in extremely steep and rocky terrain. Burning out from this line would then be required and had little chance of success. Going DIRECT would also require crews to cut handline through heavy mixed conifer on steep slopes with loose large rocks and boulders as well as snags. The distance of handline and time of exposure would be significantly less than the indirect line option. With the rain lowering the fire behavior, going direct would also shorten the timeframe of exposure to a week or so versus months of a long duration fire. On the downside, the direct option would expose crews to very steep rocky terrain in heavy mixed conifer. Preparing for the Worst All of the options available for managing the San Antonio fire carried high risk. This was acknowledged by the IMT3 as well as the USFS and NPS Line Officers, both of which were actively engaged with the IMT3 in making the decision. Leader s Intent which was articulated in the WFDSS 1 decision-- was clear Ensure firefighter safety while attempting to minimize overall fire size and manage costs. Risks should only be taken when and where there is a high probability of success in protecting important values present. Knowing that this mission carries with it a high risk, Line Officers, and the IMT3, with input from the IHCs, put a great deal of effort into mitigating risks and planning for medical evacuation. In addition, two ambulances were on scene, one on top of the fire and one at the bottom as well as a Rapid Extraction Module Support (REMS) with EMTs and Paramedics skilled at low angle rescue. The incident was also fortunate to have a Short-Haul capable Type 3 helicopter. WORKING DOWN IN THE HOLE The next two days all three crews worked down in the hole to secure the fire. Prineville and Zigzag were the primary crews working in the drainage. The crews shared the two Type 1 helicopters working the fire. The crews established a rotation: each crew would get every-other bucket. This would allow the crews to work 1 Wildland Fire Decision Support System, (WFDSS) 4

5 slowly down into the drainage towards the tie in point and provide for effective use of the full fuel cycle of the helicopter. The work in the drainage was expected to take about 1-2 operational shifts, but on the day of the accident the crews were on day 3 of this operation. Due to the steep rocky ground, heavy fuel loading and high concentration of snags, the work was slow going. It was a dirty burn and there was lots of rock moving by hand. The line dig wasn t fast, took a long time we just did what we could while the sawyers did their thing. Knocked a rock loose the first day and it really got going close to people. Set the tone for working in there. Zigzag Crewmember The falling team was doing a lot of snagging. It was described as pretty standard falling however they noticed that some trees were exploding when they hit the ground. This was assumed to be due to the fact the trees were so drought stressed. The fallers took their time and made sure they weren t leaving anything that would fall on someone. Securing the line was mostly just dealing with heavies and one hundred percenting it so we didn t have to come back. After the rain on the 16 th and 17 th, they were mainly dealing with candles, heavies and stumps but the draw was steep and rocky and the ground was saturated and slick. The crews talked about avoidance areas, snag areas, boulders and they talked about medevac, looked at safety zones and at a helispot. Though the helispot was a maybe (not approved yet), they weren t working very far away from it. JUNE 19 TH MELLOW DAY BEING SUCCESSFUL. The morning of the 19 th was described by a Zigzag crewmember this way: standard cold breakfast, pretty mellow morning, not rushed, happy not to drive, nice night, no rain, good spirits. Joel was working as the Crew Boss trainee (CRWB-T) on Zigzag and was working ahead of the crew looking at areas that would need quick attention instead of the systematic work coming down the hill. He was working with the helicopter passing it between himself, other members of Zigzag and Prineville IHC. There was no other water source out there and dry mopping wouldn t work so the water drops were necessary. Due to the rotorwash and some of the water drops from the Type 1 helicopters breaking trees, they got very strategic about the bucketwork. The crews continued getting every-other bucket to reduce the exposure and increase the time between drops which allowed for a slower pace and more time to see hazards. Joel got to the tie in point, the overlap area where Prineville had put in the saw cut and Zigzag put in the dig. He noticed a log burning l close to the line with active flame, and felt the log would produce rolling embers that could cross the hand line and cause spots. He called Prineville to request the helicopter on its next load and a saw team to come cut and mop up the log after the bucket drop. He set up a panel and got a strobe light out to help guide the helicopter in. The helicopter made two drops but missed the hotspot both times. The drops were so high that it was more like rain falling. At the time of the bucket drops, Joel was level with the canopy and clearly remembers looking at the tree but does not remember seeing any limbs hung up in the canopy. The saw team showed up just as the helicopter was making the second drop and they stayed side slope of the hotspot during the drop. After the drop, the saw team and Joel worked their way back down the slope to the hotspot to see if they could start mopping it up. It took them about 5 minutes to work down to the hotspot. As 5

6 they arrived Joel and Memo walked to the burning log and were discussing the plan to get it mopped up. As they were talking Joel heard the limb release from the tree Joel described the noise as a cracking and popping all at the same time noise. Hearing the limb release from the tree Joel knew it was coming but he could not see the limb. He looked at Memo and knew instantly the limb was going to hit them by the look on Memo s face. Memo was looking up and was starting to move. Joel was not sure what direction to go, he was not able to see the limb coming and at this point did not want to look up. I knew if I looked up I would take it right in the face. The noise is hard to explain but as a sawyer it s a noise you just know what it is when you hear it. Joel (Patient 1) Joel braced himself for the impact by shrugging his shoulders, moving his hands upward in an attempt to protect his head and started to take a step towards Memo, at the same time Memo was pushing Joel into the slope as the limb hit him with a glancing blow. It happened so fast Joel was in the process of bracing for the hit and making the first step towards Memo when the limb hit. The limb struck Joel on the left side of the hard hat at an angle smearing the hard hat off his head and knocked his phone out of his Nomex shirt pocket. The sawyer came over and put his yellow on the bleeding cut on Joel s head. It was less than 2 minutes before crew members started showing up. The log that Joel was lying next to was still burning and his feet were very close to the flame. The sawyer pulls him away. The Zigzag crew EMT took over patient care and held pressure on Joel s head. THE DOUBLE MEDEVAC TIMELINE 17:08 Zigzag Bravo James (Medical IC 1) had been posted as a lookout all day. Up on the rocks he could easily hear the voices of the crew and the branch fall. There was a weird artificial sound that he could not place then realized it was the sound of wood hitting a hard hat. Memo (a not-yet-identified second patient) watched Joel go down holding his head screaming. He kneeled down beside Joel and got on the radio stand by for a medical. Prineville IHC decided to limit the exposure to the crew by selecting only one squad to work down the slope towards Zigzag. Having one squad on the steep slope limited the number of firefighters exposed to rolling rocks, steep terrain and falling debris. This also made for slower progress on the Prineville section of the line. Two firefighters from Prineville were about 75 yards from the accident site when the accident occurred. They watched the helicopter make the drops in the area and noted the ship was dropping high to help prevent rotor wash effects on the area. The ship made two drops and then left for the dip. About 5 minutes later, one of the firefighters saw the top come out of the tree and then they both heard yelling coming from the Zigzag personnel. Knowing instantly that someone got hurt, they started working their way to the location and called the possible medical over the Prineville crew channel. As Prineville arrived, the crew Assistant Superintendent was asked to scout a possible route out the bottom of the drainage. It was quickly realized the route down was NOT an option. The terrain got worse the further he went. The Prineville Superintendent was at the DIV break talking to DIV W when the medical call was transmitted. Prineville Superintendent was driving the crew UTV and was able to quickly drive to the bottom of the drainage to help scout the down route. Once it was determined the down and out route was not an option, the Prineville Superintendent stayed at the bottom to assist the Short-Haul ship with configuration and patient 6

7 loading. The decision was made not to Short-Haul Patient 1, so the Prineville Superintendent drove the UTV back around to the top arriving just as Patient 2 was being transported. Medical Unit Leader (MEDL) was in the medical cabin at base camp when the medical incident report was called in. MEDL walked over to the communications tent, 50 feet away. (17:12 by MEDL watch) As the red priority Medical Incident Report was transmitted over command she gathered information needed to implement the medical plan and communicated with the Command and General staff at ICP via cell phone text. Rapid Extrication Module Support (REMS) At the time of the accident the REMS team was assigned to DIV W, but they were staged at the helispot in DIV E a quarter mile upslope form the accident site. They overheard the emergency traffic on DIV E tac and responded to where they believed the Zigzag crew was. Type 3 Helicopter/Short-Haul capable (8PA) was staged at the temporary incident helibase at Fenton Lake State Park when they heard the Medical Incident Report read over command. Air Attack (ATGS) was enroute to the fire and monitoring traffic. They heard that 8PA was up and talking with firefighters on ground about a medical situation going on. I know that there is Hotshot crew and a REMS on scene and they know what they are doing. ATGS began to coordinate with ground forces and Santa Fe dispatch about the medical and aircraft needs. 17:38 REMS arrived on scene and found Joel with a head laceration and complaining of back pain being treated by EMTs and members of the Zigzag crew. Having 2 paramedics, REMS took charge of patient care and made a full assessment. While conducting the patient assessment, additional members of the Santa Fe Fire Department, 3 members of a type 6 engine also assigned to the San Antonio fire and members of the Santa Fe REMS program, arrived on site to assist. After their assessment, the patient was downgraded to a Priority 2 Yellow. 17:40 Joel is downgraded to yellow. As he was being packaged for transport, 8PA performs recon of the accident site and made positive contact with ground resources. They observed the location of the patient s position on slope, steepness of terrain, as well as canopy openings and recommended a Short-Haul. At the time they saw Joel and some other personnel but do not see the full number of personnel in DIV E. The REMS and the 3 IHC Superintendents have a conversation about the risk of Short- Haul over conveyor belt transportation. It was decided that due to the injuries not being life threating, that the helicopter still would have to configure for the mission, and that they had three hotshot crews on site, the least risky mode of transport would be to conveyor belt the patient to the top of the hill and transport via UTV to the approved helispot (H2) that was just a quarter mile away. 7

8 Joel was completely packaged and ready for transport. The Medical IC called 8PA and informed them that the patient will be transported via conveyor belt. The Medical IC also requested that the Short-Haul ship move to the helispot to pick up the patient and transport him to the Santa Fe Hospital. 17:49 Conveyor belt transport starts with Patient 1. Water Flowing Uphill 18:08 Memo starts to feel the effects of the limb strike and realizes he is actually hurt. He had stepped away from his position in the treatment of Joel and sat down on a rock just above the accident site. A squad leader from Prineville noticed he had sat down and motioned to a Prineville EMT to check him out. As the EMT was assessing Memo, the second paramedic from the REMS walked over and started a full assessment. Memo was complaining of mid back pain, but was insistent that he could hike out under his own power. During the assessment, the paramedic was able to gather that Memo took a glancing blow to the back as he was pushing Joel out of the way of the falling limb. Due to the mechanism of injury, the paramedic felt it would be best for Memo to be secured to a backboard and transported by conveyor belt to the top of the hill and then 8

9 to the helispot. The REMS paramedic and the Zigzag Superintendent decided to handle Memo as a separate incident with a separate Medical IC and wait until Joel was at the top of the hill before transmitting the Medical Incident Report for Memo. He also needed to be transported with full spinal precautions but could wait until after Joel was at the UTV. They agreed that resources needed to concentrate on getting Joel over the roughest terrain and then would reset the conveyor belt for Memo. 18:11 Joel arrives at the top of the hill. Zigzag Alpha calls in Medical Incident Report for Patient 2 Memo-- as a priority yellow. The REMS paramedic, with help from the firefighters was still at the accident site, and packaging Memo on the backboard. 18:21 Joel arrives at UTV. 18:35 Joel arrives at the Cabin helispot (secondary location) and patient care was transferred to the paramedic on board the 8PA and transported to the hospital. 18:38 As Memo is being conveyor belted to the top of the hill, the crew had improved their efficiency of the movement and was moving him up the hill extremely fast. At this point there were 4 hotshot crews assisting in the conveyor belt and all movements were performed safely and efficiently. The conveyor belt for Memo following the same path taken by Joel but it only took 15 minutes to get Memo to the UTV almost twice as fast. 18:50 ATGS asks Santa Fe dispatch about a second helicopter for medevac; dispatcher informs ATGS of a Type 2 at Santa Fe airport. 18:51 Dispatch calls the helicopter manager (HMGB) of the Type 2 helicopter requesting them for medical transport. While HMBG was on the phone with dispatch, the crew was configuring the ship for medical transport, downloading all unnecessary cargo, installing backboard etc. HMGB decided to send along HECM to assist the treating EMT as needed. 19:04 MEDL and COML now realize the medical incident had switched to Air to Ground and that the medical incident was being facilitated through Air Attack. MEDL is only able to hear what is said by the aircraft over the site but believes the on the ground coordination is going very well and stepped back and let the response happen, trusting the REMS to use their experience to request the appropriate resources for the incident. REMS makes the decision that both patients would go to St. Vincent s hospital in Santa Fe. 19:20-19:25 Type 2 helicopter lands at the helispot where Memo Patient 2 (packaged in litter) and EMT are awaiting transport. 19:37 Type 2 helicopter lifts off and calls Santa Fe dispatch with a 15 minute ETE to St. Vincent s Hospital in Santa Fe. When asked, the dispatcher did not have a frequency for the hospital. 19:54 Upon arriving overhead of the hospital and locating the secondary landing zone in parking lot (as well as a recon of the actual helipad), the pilot determines that the established helipad was a better option, notifies dispatch, and lands. Hospital personnel unload patient, and transfer him to the Emergency Room. 01:15 Both Zigzag firefighters are released from the hospital. 9

10 San Antonio Fire FLA LEARNING SHARED Use of a Marshaller - Due to the rough, steep and rocky terrain one person was assigned to marshal (direct and guide) personnel as they lined out for the conveyor belt. This person stood in front of the conveyor belt line and directed them around clusters of loose rocks, unstable footing and heavy dead and down. This coordination and direction made for a much faster and stable transport of Joel. He was transported from the accident sight to the awaiting UTV in 31 minutes. Several times during the transport folks would be reminded to slow down slow is smooth, smooth is fast, to watch their footing and to watch the handholds. Use of the Conveyor Belt - During the conveyor belt transport the REMS identified a portion of the steep slope they felt having a rope system to provide mechanical advantage would be good and safer for the patient. As the REMS started to get the rope system set up the conveyor belt transport system blew right past them. The speed of the conveyor belt transport system was completely mind blowing to the REMS and they were extremely impressed by the efficiency and safety of the patient movement. The wearing of line gear while performing the conveyor belt patient transport method causes firefighters to be off balance on uneven terrain. Causes more fatigue during the high paced transport. It is recommended that during medical emergencies crews drop their line gear to improve safety during patient transport, but crews also need to keep the full fire situation in mind before dropping the gear: Is the patient transport going into the green with unchecked fire activity? Is the patient transport going to be completed before the fire overtakes the operation? Have you practiced getting a patient on a backboard into a fire shelter? A rigid backboard is much easier, faster and more comfortable for the One firefighter patient to use during the conveyor belt transport method than a Sked. described the The back board has several hand holds along the full length of the board. The Sked unit is flexible and only has 6 hand hold loops movement of the limiting the number of personnel who can hold and pass the sked unit conveyor belt like along. During the transport of Patient 1 several times the hand hold water flowing uphill loops at the patient s head were grabbed causing flexing of the patients neck causing additional pain. o o o 10

11 Utilizing the REMS team - The REMS team was from the local area, Santa Fe Fire Department, and had extensive knowledge of the level of medical care available at each hospital. The REMS team had 2 EMTS and 2 Paramedics assigned who were all trained in rope rescue systems and wildland fire. Have face to face conversations with REMS team assigned to your division to discuss capabilities, equipment familiarization and to find opportunities to conduct impromptu hands on training on the terrain the crews are working on.(ihc suggestion) Request the REMS team, if capable, to have the full team or a member of their team on site with the crews as they are progressing deeper into nasty terrain instead of staging at the helispot. (IHC suggestion) Being a local resource the REMS were able to select the most appropriate hospital to receive both patients. The closest hospital, Las Alamos, does not have trauma capabilities and Saint Vincent s Hospital in Santa Fe was the most appropriate location for treatment. The injuries or mechanism of injury did not warrant transportation to the Level 1 trauma center. Consider what type and number of resources are helping when determining patient transportation method. (REMS suggestion) Monitor tac channels and have conversations with resources on the fire to determine the quickest route to their work location in the event of an emergency. (REMS suggestion) Scout and cut evacuation routes to allow quicker and closer access with UTV. (REMS suggestion) A camouflage UTV is difficult to see in dense vegetation; use brightly colored paint or high visibility flagging on rescue/ transport equipment. (IHC suggestion) Training for Medical Emergencies IHC medical incident training has always evolved around having one patient. During future trainings we will train for multiple patients with one of the patients being a member of the overhead of the crew. IHC Asst. Superintendent. Having both patients called in at the same time could have cleared up a lot of confusion that occurred during the upward notification process about the number of patients, number of accidents and location patients were being transported to. (IHC suggestion) This type 3 team doesn t have accidents like this, all my years with this team, this is our first Priority Red medical. IMTs could benefit from practicing medical emergencies. (MEDL suggestion) The REMS team had been training with the knowledge they had about patient transport in remote steep area using only limited personnel and rope rescue techniques. The conveyor belt transport system was new to the Santa Fe REMS, they were completely blown away by the safety, speed and efficiency of this transport method. Santa Fe REMS will in the future train using the conveyor belt transport method. Seeing the conveyor belt transport method blew our training box WIDE OPEN in a good way. (REMS suggestion) Over-train for medical emergencies with the hope your training is underutilized Zigzag IHC Superintendent Consider the risk to personnel when faced with Short-Haul versus carry out. Have a conversation with the Short-Haul crew on weighing the risks. In the case of this FLA, there were plenty of resources to extricate both patients safely and the decision to carry out the patients made sense. 11

12 The Medical Plan - During team planning meetings the medical plan was discussed. The established plan was that any medical incident response would be coordinated by the MEDL. There were assumptions made by the IMT3 that the IAPs and morning briefing were getting to everyone but IHCs weren t consistently getting IAPs until after the accident and No 220 had been included in the IAP until after the accident. Additionally, nothing was shared with the aviation resources on the fire. Some of the information on the medical plan, including several coordinates, were inaccurate. The host unit should confirm that information in the Medical Plans is correct. This can be done preseason and thoroughly checked annually. (Do you take Med Plans from old IAP s and use them again? Make sure Aircraft assigned to Incident are listed in IAP. Make sure your aviation resources are briefed. Make sure ALL resources are receiving IAPs. Identify the capabilities of the local air ambulance services. Identify which local hospitals will allow an agency aircraft to land on their helipad and what size helicopter. Give more clarity to line EMTs and REMS on how the medical plan is to be used but also to stay flexible with the plan to allow for onsite changes. (MEDL suggestion) When switching frequencies for an Incident within an Incident, make the appropriate notifications. (MEDL suggestion) MEDL deferred to the experience of the REMS team to provide the most appropriate care for the patients. DISCUSSION QUESTIONS AND ACTION ITEMS So let s look at the accident. Joel and Memo were a part of a direct suppression strategy. They were in steep, rugged terrain. They didn t do any of those things that other lessons learned have shown such as: they were not cutting the tree they did not walk under a bucket drop they didn t rush in after bucket drops they were looking up/down and around and aware of their surroundings they HAD situational awareness They were there for a good reason, they were cautious, they have good experience to know what to watch out for yet they were both hurt. FOR FIREFIGHTERS READING THIS FLA: This is a quote from Joel (Patient 1) We choose to fight fire, it s a hazardous job but no matter how much you try; you can t mitigate all the possible hazards out there in this dynamic environment. Question: Is this true? Do we go to work every day knowing we could get hurt? Is that just what fighting fire is? Question: If you have an Acceptable Risk, do you then also have an Acceptable Loss? Question: What if there are only three firefighters (engine crew/helitack for example) on a remote fire what are your plans for evacuation? 12

13 Question: Is it possible to have a Green patient, but a Red evacuation? Can you minimize risk by Short-Haul versus long carry out in difficult terrain? Action Item: Is YOUR crew ready for a 2 person medevac? How is YOUR crew going to be better prepared for this possibility? FOR INCIDENT OVERHEAD READING THIS FLA: Like many fires, the decision to go direct or indirect forces decision-makers to intentionally choose between alternatives that can ALL carry very high risk. Even the very best decision can expose firefighting personnel to very high risk situations. In the San Antonio Fire, there were very compelling reasons to go direct that made sense. Question: If your team makes plans for IF someone gets hurt vs EXPECTING someone to get hurt, would that change the urgency and thoroughness of your emergency planning efforts? Action Item: Consider doing a medical emergency training scenario with your team. FOR AGENCY ADMINISTRATORS READING THIS FLA: Wildfires are a complex, dynamic and often unpredictable phenomenon While the magnitude and the complexity of the fire itself and of the human response to it will vary, the fact that fire operations are inherently dangerous will never change. A firefighter utilizing the best available science, equipment, training and working within the scope of agency doctrine and policy, can still suffer serious injury or death. (Interagency Standards for Fire and Fire Aviation Operations 2018) Question: So why did Joel and Memo get hurt? Could the answer be Because that s how we fight fire? Is this acceptable? If so, is this actually acceptable loss? Question: If we continue fighting fire like we do now, should we simply expect that someone will get hurt? Question: If we expect that someone will get hurt, will we place more emphasis, urgency and thoroughness on our medical care and evacuation planning? Or will we chose NOT to expose responders to certain types of hazards, and shift our view of what hazards ARE acceptable? Action Item: Agency Administrators need to understand that when there is a fire there is no risk free option and therefore be prepared both mentally and administratively for serious accidents or incidents to happen. 13

14 The Facilitated Learning Analysis Team MIKE LEWELLING Team Lead; National Park Service Fire Management Officer Rocky Mountain National Park DALE SNYDER SME; U.S. Forest Service Assistant Fire Management Officer National Forests and Grasslands in Texas MACK MCFARLAND SME; National Park Service Safety Officer Grand Teton National Park TRAVIS STANFILL SME; U.S. Forest Service Douglas Helitack Superintendent Coronado National Forest KATHY KOMATZ Writer/Editor, National Park Service Training Specialist Fire and Aviation Management 14