Accident Investigation Guide: 2005 Edition

Chapter 8—Wildland Fire Shelter Entrapments, Deployments, and Fatalities

8.1 General

The following information is specific for wildland fire shelter entrapments, deployments, and fatalities. The investigation process and development of the factual and management evaluation sections need to follow procedures already established in this guide.

8.2 Scope and Purpose

Wildland firefighters are members of a relatively small community and operate under a concept of total interagency mobilization that moves firefighters across the country as easily as rural departments move across county lines. Because of this mobility, information about specific fire-related accidents or incidents and the lessons learned from these situations must be disseminated to all firefighters quickly and thoroughly. Most wildland fire agencies that experience a burnover or fatality conduct an investigation to review the circumstances of the incident. Such a review can provide important insights and recommendations to improve wildland fire safety.

8.3 Wildland Fire Shelter Entrapments, Deployments, and Fatalities Protocol

In a wildland fire environment:

• A deployment refers to the use of a fire shelter.
  
  
• “An entrapment is a situation where personnel are unexpectedly caught in a fire-behavior-related, life-threatening position where planned escape routes or safety zones are absent, inadequate, or have been compromised. An entrapment may or may not include deployment of a fire shelter for its intended purpose.” (Investigating Wildland Fire Entrapments: 2001 Edition, 0151–2823–MTDC)
  
  
  • All motorized fire equipment vehicles (such as engines) involved in a burnover will be considered an entrapment.
    
    
  • A fatality is any death that occurs in the line of fire duty.

1. Initial Response. The unit or incident management team that has experienced a fire entrapment, deployment, and/or fatality needs to take some immediate actions before the investigation team arrives. The fire entrapment/fatality first response form needs to be completed and transmitted to the agency administrator and investigation team leader (exhibit 8–1).
   
   Also, the unit or incident management team shall report preliminary information about a fire entrapment, deployment, and fatality associated with wildland fire operations on the wildland fire fatality and entrapment initial report form (NFES No. 0869). This form must be forwarded to the agency administrator and the National Interagency Coordination Center within 24 hours of the fire-related accident or incident (exhibit 8–2).
   
   
2. Team Composition. As soon as a fire entrapment, deployment, and/or fatality occurs, the agency having jurisdiction establishes an investigation team for the incident.
   
   A chief investigator is assigned from the lead agency on whose land the entrapment occurred or whose firefighters were involved. The memorandum of understanding between the United States Departments of the Interior and Agriculture documents the assignment (exhibit 8–3). In cases where two jurisdictions are involved, dual chief investigators may be named. Other individuals normally assigned to a fire-related investigation in addition to the regular team members are:
   
   
   • Fire operations expert
     
     
   • Fire behavior analyst (with experience in the fuel type where the incident occurred)
     
     
   • Fire weather meteorologist from the United States Department of Commerce National Oceanic and Atmospheric Administration’s Fire Weather Service
     
     
   • Fire equipment specialist from the Missoula Technology and Development Center
     
     
   • Technical (professional) photographer
     
     
   • Fire information officer
   
   These team members should be selected from outside the region/forest unit where the accident or incident occurred.
   
   
3. Notification. As soon as an entrapment, deployment, and/or fatality are verified, the local unit dispatcher should make the following contacts:
   
   
   1. Forest Service law enforcement personnel should be requested to help secure the site.
      
      
   2. In the case of a fatality, notify the county sheriff who will notify the coroner/medical examiner.
      
      
   3. Other notifications that should take place are:
      
      
      • National Interagency Coordination Center.
        
        
      • Higher level headquarters (region, station, and area safety managers).
        
        
      • United States Department of Labor Occupational Safety and Health Administration. (Notification within 8 hours for all fatalities and hospitalizations of three or more employees.)
        
        
      • Other agencies and individuals as required by incident response plans.
        
        
4. Activities at the Accident Site. When a fatality occurs during a fire-related accident, the victim should not be moved without specific permission of the county sheriff or coroner/medical examiner. Injured persons should receive emergency medical treatment and be taken to a medical facility as soon as possible.
   
   Tools, vehicles, personal equipment, personal protective equipment (including fire shelters), and other associated items should be left where they are until the chief investigator clears them for removal. Law enforcement personnel should secure the site from outside disturbance and from unauthorized visits by the media. Information gathered at the site of an entrapment is often critical in reconstructing the events that occurred and for identifying lessons that can be learned to avoid similar accidents in the future.
   
   Review the fire entrapment/fatality first-response form for additional steps to be taken before the investigation team arrives (exhibit 8–1).
   
   
5. Investigation Elements.
   
   
   • Fire behavior
   • Environmental factors
   • Incident management
   • Control mechanisms
   • Personnel profiles of those involved
   • Equipment
     
     Exhibit 8–4 shows the entrapment investigation elements matrix. It is designed as a checklist to assist team members involved in entrapment investigations in identifying elements involved in the accident/incident event. It is not designed to be used as a report format.
     
     
6. Investigation Team Activities.
   
   
   • Once the investigation team arrives, the team undertakes the following tasks at the direction of the Chief Investigator:
     
     
     • Photograph the entire scene before any items are removed. Specific areas requiring photographic documentation include overviews of the accident or incident scene from the air. Aerial photographs show critical factors such as fuel types and burn patterns that may have contributed to the accident or incident. When photographing from helicopters, avoid disturbing the site with rotor downwash.
       
       
     • Include general area photographs of the scene from the ground and large-format closeups of damage to personal protective equipment and other firefighting equipment. Laying a new yellow Nomex shirt and green Nomex trousers where an individual was burned over helps to show conditions as they were found.
       
       
     • Prepare a detailed site diagram showing the specific location of individuals, equipment, roads, structures, and other important features. Small accident or incident scenes can be mapped using a compass and the pacing method from known landmarks or control points. At accident or incident scenes covering more than a 3/8-mile area, Global Positioning System (GPS) locations may be useful. A detailed site diagram is an essential part of the final investigation report.
       
       
     • After the visual review has been completed, individual items of personal protective clothing and other equipment should be collected, tagged to indicate who used them, and taken to the investigation team headquarters. These items should be protected and secured in the same manner as evidence.
       
       
     • Natural terrain features at accident or incident scenes can provide valuable information. Slope, aspect, drainage, fuel type, fuel loading, heat-set on grass and needles, and evidence of winds can help the investigator determine the events that led to the entrapment.
       
       
7. Analysis of Personal Protective Equipment. PPE should be inspected for compliance with Forest Service policies for mandatory and optional equipment for wildfires. It should also be inspected to determine the manufacturer and whether the equipment was constructed in accordance with accepted standards. The National Fire Protection Association (NFPA) 1977 compliance label is a good indicator of compliance.
   
   Clothing subjected to radiant heat or direct flame should be compared with industry examples to show temperature ranges in the deployment, entrapment, or fatality. Comparing the condition of burned equipment with the design standard can often help determine the survivability of a fire-related accident.

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