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Diamond Fire: Serious Accident Investigation ReportAuthor(s): John Waconda; Ivan Pupulidy; Leonard Diaz; Robin Broyles; Roberta Junge; James Saveland
Source: Whiteriver, AZ: White Mountain Apache Tribal Council, Fort Apache Agency. 30 p.
Publication Series: Miscellaneous
Station: Rocky Mountain Research Station
PDF: Download Publication (5.88 MB)
DescriptionThis incident is effectively two studies. The first study, and the reason the Serious Accident Investigation Team was assembled, was due to a fatality, which the autopsy later determined to have been caused by a heart attack. The team was not aware of the cause of death for over 4 weeks after the incident occurred. However, the observed and reported cases of heat stress symptoms, on the part of surviving members of the crew, made it necessary to fully explore the conditions surrounding heat illness. The second study was driven by the potential for additional loss of life, which existed in the multiple near miss situations of hyperthermia. High Reliability Theory suggests taking near misses as seriously as accidents, as they can provide insights into prevention.
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CitationWaconda, John; Pupulidy, Ivan; Diaz, Leonard; Broyles, Robin; Junge, Roberta; Saveland, James. 2012. Diamond Fire: Serious Accident Investigation Report. Whiteriver, AZ: White Mountain Apache Tribal Council, Fort Apache Agency. 30 p.
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