+-----------------------------------------------------------------------+
| #                                                                     |
|                                                                       |
| **Participants Manual**                                               |
|                                                                       |
| # SERIOUS ACCIDENT INVESTIGATION COURSE                               |
+-----------------------------------------------------------------------+
| **LESSON 9: Wildland Fire Accident Investigation**                    |
+-----------------------------------------------------------------------+
| **INSTRUCTOR:**                                                       |
+-----------------------------------------------------------------------+
| **Objectives:**                                                       |
|                                                                       |
| **After completing this lesson the participants will be able to:**    |
|                                                                       |
| -   **Understand accident investigation processes for Wildland        |
|     Fire.**                                                           |
|                                                                       |
| -   **List the additional requirements for investigating fire         |
|     accidents.**                                                      |
|                                                                       |
| -   **Determine technical specialists unique to fire accident         |
|     investigations.**                                                 |
|                                                                       |
| -   **Understand the Firefighter Autopsy Protocol.**                  |
|                                                                       |
| -   **Examine and collect PPE evidence from wildland fire             |
|     investigations.**                                                 |
|                                                                       |
| -   **Identify the types of document evidence that should be          |
|     collected for wildland fire investigations.**                     |
|                                                                       |
| > SAIT Resource Documents (USB Flash drive):                          |
|                                                                       |
| -   Interagency Standards for Fire and Fire Aviation Operations (Red  |
|     Book) Chapter 7                                                   |
|                                                                       |
| -   Interagency Standards for Fire and Fire Aviation Operations (Red  |
|     Book) Chapter 18                                                  |
+-----------------------------------------------------------------------+

+--------------------------------------------+-------------------------+
| **Unit Title: Wildland and Prescribed Fire |                         |
| Accident Investigation**                   |                         |
+============================================+=========================+
| **Lesson 9:**                              | **Notes**               |
+--------------------------------------------+-------------------------+
| **DEPARTMENT OF INTERIOR POLICY**          |                         |
|                                            |                         |
| For DOI Wildland Fire agencies, the DASHOs |                         |
| have delegated the authority to appoint a  |                         |
| SAIT to the respective agency's fire       |                         |
| directors for serious wildland fire        |                         |
| accidents.                                 |                         |
|                                            |                         |
| **OTHER POLICY**                           |                         |
|                                            |                         |
| **MOU USDI and USDA**                      |                         |
|                                            |                         |
| As an outcome of the 1994 South Canyon     |                         |
| investigation the Departments of Interior  |                         |
| and Agriculture signed a Memorandum of     |                         |
| Understanding in October of 1995 (Handout  |                         |
| 9-1), establishing that wildland fire      |                         |
| serious accident investigation teams will  |                         |
| be interagency teams.                      |                         |
|                                            |                         |
| > **The MOU also addresses:**              |                         |
|                                            |                         |
| -   Co-lead investigations                 |                         |
|                                            |                         |
| -   Agency-lead investigation              |                         |
|                                            |                         |
| -   Report time frames                     |                         |
|                                            |                         |
| -   Team training and qualifications       |                         |
|                                            |                         |
| Interagency Standards for Fire and Fire    |                         |
| Aviation Operations (Red Book) Chapter 18, |                         |
| provides guidance and procedures for fire  |                         |
| related accidents, entrapments and shelter |                         |
| deployments. A copy of that chapter is     |                         |
| included in the SAIT Resource Documents on |                         |
| your USB flash drive.                      |                         |
|                                            |                         |
| The "Red Book" is revised annually with    |                         |
| updates posted in January at the following |                         |
| web site:                                  |                         |
|                                            |                         |
| **h                                        |                         |
| ttp://www.nifc.gov/policies/red_book.htm** |                         |
|                                            |                         |
| **INVESTIGATION CATAGORIES**               |                         |
|                                            |                         |
| Wildland Fire related accidents requiring  |                         |
| investigations are organized into the      |                         |
| following categories:                      |                         |
|                                            |                         |
| **Serious Wildland Fire Accident**         |                         |
|                                            |                         |
| An unplanned event or series of events     |                         |
| that resulted in death; injury;            |                         |
| occupational illness; or damage to or loss |                         |
| of equipment or property. For wildland     |                         |
| fire operations, a serous accident         |                         |
| involves any of the following:             |                         |
|                                            |                         |
| -   One or more fatalities                 |                         |
|                                            |                         |
| -   Three or more personnel who are        |                         |
|     inpatient hospitalized as a direct     |                         |
|     result of or in support of wildland    |                         |
|     fire operations.                       |                         |
|                                            |                         |
| -   Property or equipment damage of        |                         |
|     \$250,000 or more.                     |                         |
|                                            |                         |
| -   Consequences that the Designated       |                         |
|     Agency Safety and Health Official      |                         |
|     (DASHO) judges to warrant Serous       |                         |
|     Accident Investigation                 |                         |
|                                            |                         |
| **Non-Serious Wildland Fire Accident**     |                         |
|                                            |                         |
| An unplanned event or series of events     |                         |
| that resulted in injury; occupational      |                         |
| illness; or damage to or loss of equipment |                         |
| or property to a lesser degree than        |                         |
| defined in "serious wildland fire          |                         |
| accident".                                 |                         |
|                                            |                         |
| **Near-Miss**                              |                         |
|                                            |                         |
| An unplanned event or series of events     |                         |
| that could have resulted in death; injury; |                         |
| occupational illness; or damage to or loss |                         |
| of equipment or property but did not.      |                         |
|                                            |                         |
| **Entrapment**                             |                         |
|                                            |                         |
| 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    |                         |
| compromised. Entrapment may or may not     |                         |
| include deployment of a fire shelter for   |                         |
| its intended purpose (NWCG Glossary of     |                         |
| Fire Terminology). Entrapment may result   |                         |
| in a serous wildland fire accident, a      |                         |
| non-serous wildland fire accident, or a    |                         |
| near-miss.                                 |                         |
|                                            |                         |
| **Fire Shelter Deployment**                |                         |
|                                            |                         |
| The removing of a fire shelter from its    |                         |
| case and using it as protection against    |                         |
| fire (NWCG Glossary of Fire Terminology).  |                         |
| Fire shelter deployment may or may not be  |                         |
| associated with entrapment. Fire shelter   |                         |
| deployment may result in a serious         |                         |
| wildland fire accident, a non-serious      |                         |
| wildland fire accident, or a near-miss.    |                         |
| Any time a fire shelter is deployed (other |                         |
| than for training purposes); regardless of |                         |
| circumstances, notification of the         |                         |
| National Fire and Aviation Safety Officer  |                         |
| of the jurisdictional agency is required.  |                         |
|                                            |                         |
| **Review and Investigation Requirements**  |                         |
|                                            |                         |
| +------------+------------+------------+   |                         |
| | **         | *          | **         |   |                         |
| | Wildland** | *Review/** | Management |   |                         |
| |            |            | level that |   |                         |
| | **Fire**   | **Inv      | determines |   |                         |
| |            | estigation | review     |   |                         |
| | **Event**  | Type**     | type and   |   |                         |
| |            |            | authorizes |   |                         |
| |            |            | review**   |   |                         |
| +------------+------------+------------+   |                         |
| | Serious    | Serious    | National   |   |                         |
| | Wildland   | Accident   |            |   |                         |
| | Fire       | Inv        |            |   |                         |
| | Accident   | estigation |            |   |                         |
| |            | (SAI)      |            |   |                         |
| +------------+------------+------------+   |                         |
| | N          | N          | Regional/S |   |                         |
| | on-Serious | on-Serious | tate/Local |   |                         |
| | Wildland   | Accident   |            |   |                         |
| | Fire       | Inv        |            |   |                         |
| | Accident   | estigation |            |   |                         |
| |            | (NSAI)     |            |   |                         |
| +------------+------------+------------+   |                         |
| | Near-miss  | Lesson     | Regional/S |   |                         |
| |            | Learned    | tate/Local |   |                         |
| |            | Review     |            |   |                         |
| |            | (LLR)      |            |   |                         |
| +------------+------------+------------+   |                         |
| | Entrapment | SAI, NSAI, | National   |   |                         |
| |            | LLR,       |            |   |                         |
| |            | depending  |            |   |                         |
| |            | on         |            |   |                         |
| |            | severity   |            |   |                         |
| +------------+------------+------------+   |                         |
| | Fire       | SAI, NSAI, | National   |   |                         |
| | Shelter    | LLR,       |            |   |                         |
| | Deployment | depending  |            |   |                         |
| |            | on         |            |   |                         |
| |            | severity   |            |   |                         |
| +------------+------------+------------+   |                         |
|                                            |                         |
| Remember that all of these categories      |                         |
| apply to any Wildland fire suppression,    |                         |
| prescribed fire or training activity.      |                         |
|                                            |                         |
| **UNIT RESPONSIBILITIES**                  |                         |
|                                            |                         |
| The unit or incident management team that  |                         |
| has experienced the accident needs to      |                         |
| carry out immediate response actions.      |                         |
|                                            |                         |
| -   One action is submitting the Wildland  |                         |
|     Fire Entrapment/Fatality Report PMS    |                         |
|     405-1 (Handout 9-2) to NICC.           |                         |
|                                            |                         |
|     -   The Team Leader should request a   |                         |
|         copy.                              |                         |
|                                            |                         |
|     -   The 24 Hour Report is routinely    |                         |
|         based on this information (minus   |                         |
|         names of injured victims). This    |                         |
|         report is normally submitted by    |                         |
|         unit sustaining serious accident.  |                         |
|                                            |                         |
| This provides valuable initial information |                         |
| to the investigation team.                 |                         |
|                                            |                         |
| **ORGANIZATION OF THE TEAM**               |                         |
|                                            |                         |
| A Wildland Fire Serious Accident           |                         |
| Investigation Team includes the same       |                         |
| positions as other investigations          |                         |
|                                            |                         |
| Examples of technical specialists used     |                         |
| that are unique to these types of          |                         |
| investigations are:                        |                         |
|                                            |                         |
| -   Fire Management Officer                |                         |
|                                            |                         |
| -   Fire Operations Expert                 |                         |
|                                            |                         |
| -   Fire Behavior Analyst (with experience |                         |
|     in the fuel type where the accident    |                         |
|     occurred)                              |                         |
|                                            |                         |
| -   Fire Weather Meteorologist from the    |                         |
|     National Oceanic and Atmospheric       |                         |
|     Administrations Fire Weather Service   |                         |
|     (IMET)                                 |                         |
|                                            |                         |
| -   Fire Safety Officer                    |                         |
|                                            |                         |
| -   Fire Equipment Specialist              |                         |
|                                            |                         |
| -   Technical Professional Photographer    |                         |
|                                            |                         |
| -   GIS Specialist                         |                         |
|                                            |                         |
| **It's important to have these team        |                         |
| members selected from outside the unit     |                         |
| where the accident occurred.**             |                         |
|                                            |                         |
| **VISITS TO THE INCIDENT**                 |                         |
|                                            |                         |
| **Visits to the Incident Base**            |                         |
|                                            |                         |
| The minimum recommendation for Personal    |                         |
| Protective Equipment (PPE) at the incident |                         |
| base is the same as all field locations.   |                         |
|                                            |                         |
| Refer to the Interagency Fire and Fire     |                         |
| Aviation Operations handbook (Red Book),   |                         |
| chapter 7 (USB flash drive), the minimum   |                         |
| requirements are:                          |                         |
|                                            |                         |
| -   Lace-up, closed toe shoes/boots with   |                         |
|     traction soles and support.            |                         |
|                                            |                         |
| -   Long trousers                          |                         |
|                                            |                         |
| -   Long sleeve shirt                      |                         |
|                                            |                         |
| -   For agency personnel, the field        |                         |
|     uniform is appropriate.                |                         |
|                                            |                         |
| **Visits to the Fire Line**                |                         |
|                                            |                         |
| When interviews need to be scheduled with  |                         |
| incident personnel the Chief Investigator  |                         |
| should facilitate this with the Incident   |                         |
| Management team or the local unit.         |                         |
|                                            |                         |
| When scheduling visits to the fireline, we |                         |
| recommend the following:                   |                         |
|                                            |                         |
| -   Advance notification should be given   |                         |
|     to the Incident Management Team i.e.   |                         |
|     Incident Commander or delegated        |                         |
|     representative.                        |                         |
|                                            |                         |
| -   The IC will likely assign a liaison to |                         |
|     the SAIT to ensure this coordination   |                         |
|     takes place                            |                         |
|                                            |                         |
| Visitors must have the approval of the     |                         |
| Incident Commander (IC). Visitors must     |                         |
| maintain communications with the           |                         |
| Division/Group Supervisor or the           |                         |
| appropriate fireline supervisor of the     |                         |
| area they are visiting.                    |                         |
|                                            |                         |
| Wildland Fire Investigation teams will     |                         |
| need specific PPE and basic training as    |                         |
| required by NWCG.                          |                         |
|                                            |                         |
| Required Fireline Personal Protective      |                         |
| Equipment:                                 |                         |
|                                            |                         |
| -   Wildland Fire Boots -- a minimum of    |                         |
|     8-inch high, lace-type exterior        |                         |
|     leather work boots with Vibram-type or |                         |
|     lug, melt resistant soles. The 8-inch  |                         |
|     height requirement is measured from    |                         |
|     the bottom of the heel to the top of   |                         |
|     the boot. All boots that meet the      |                         |
|     footwear standard as described above   |                         |
|     are authorized for firefighting.       |                         |
|                                            |                         |
| -   Fire Shelter (**NOTE:** New Generation |                         |
|     fire shelters will replace existing    |                         |
|     stock of old fire shelters by January  |                         |
|     1, 2010.                               |                         |
|                                            |                         |
| -   Hard hat with chinstrap                |                         |
|                                            |                         |
| **Visits to the Fire Line(continued)**     |                         |
|                                            |                         |
| -   Yellow Aramid shirt                    |                         |
|                                            |                         |
| -   Aramid trousers                        |                         |
|                                            |                         |
| -   Leather gloves                         |                         |
|                                            |                         |
| -   Wear additional PPE as identified by   |                         |
|     local conditions, material safety data |                         |
|     sheet (MSDS) or JHA/Risk Assessment    |                         |
|                                            |                         |
| Required equipment/supplies:               |                         |
|                                            |                         |
| -   Hand Tool                              |                         |
|                                            |                         |
| -   Water canteen                          |                         |
|                                            |                         |
| The SAIT should have these items or make   |                         |
| arrangements to obtain these items upon    |                         |
| arrival                                    |                         |
|                                            |                         |
| Visits to the fireline may be "Escorted"   |                         |
| or "Non-Escorted" depending on the         |                         |
| following requirements:                    |                         |
|                                            |                         |
| **Non- Escorted:**                         |                         |
|                                            |                         |
| > Visitors must have successfully          |                         |
| > completed the Work Capacity Test (WCT)   |                         |
| > at the "light" fitness level.            |                         |
|                                            |                         |
| -   Must have adequate communications and  |                         |
|     radio training                         |                         |
|                                            |                         |
| -   Completed the following training:      |                         |
|                                            |                         |
|     -   Introduction to Fire Behavior      |                         |
|         (S190)                             |                         |
|                                            |                         |
|     -   Firefighter training (S-130)       |                         |
|                                            |                         |
|     -   Annual Fire Safety Refresher       |                         |
|         Training                           |                         |
|                                            |                         |
| > Deviation from this requirement must be  |                         |
| > approved by the IC for other             |                         |
| > non-escorted support personnel involved  |                         |
| > in vehicle operations or other support   |                         |
| > functions or established roadways and    |                         |
| > working in areas which pose no fire      |                         |
| > behavior threat.                         |                         |
| >                                          |                         |
| > **Escorted personnel:**                  |                         |
| >                                          |                         |
| > All non- incident, non-agency, visitors, |                         |
| > lacking the above training and physical  |                         |
| > requirements must be escorted while on   |                         |
| > the fireline.                            |                         |
|                                            |                         |
| -   Visitors must receive training in the  |                         |
|     proper use of PPE.                     |                         |
|                                            |                         |
| -   Requirement for hand tool and water to |                         |
|     be determined by escort.               |                         |
|                                            |                         |
| -   Visitors must be able to walk in       |                         |
|     mountainous terrain and be in good     |                         |
|     physical condition with no known       |                         |
|     limiting conditions.                   |                         |
|                                            |                         |
| -   Escorts must be minimally qualified at |                         |
|     the Single Resource Boss. Any          |                         |
|     deviation from this requirement must   |                         |
|     be approved by the Incident Commander  |                         |
|                                            |                         |
| > **Helicopter Flights**                   |                         |
| >                                          |                         |
| > Visitors who take helicopter flights     |                         |
| > must receive a passenger briefing and    |                         |
| > meet the following requirements:         |                         |
|                                            |                         |
| -   Required PPE:                          |                         |
|                                            |                         |
|     -   Flight helmet                      |                         |
|                                            |                         |
|     -   Leather boots                      |                         |
|                                            |                         |
|     -   Fire-resistant clothing            |                         |
|                                            |                         |
|     -   All leather or leather and Aramid  |                         |
|         gloves                             |                         |
|                                            |                         |
| > Occasional passengers/visitors have no   |                         |
| > training requirement, but a qualified    |                         |
| > flight manager must supervise loading    |                         |
| > and unloading of passengers.             |                         |
|                                            |                         |
| **ACTIVITIES AT THE ACCIDENT SITE**        |                         |
|                                            |                         |
| Information you have been given in         |                         |
| previous lesson plans will apply to        |                         |
| Wildland Fire Accidents Investigations.    |                         |
| Investigators should examine PPE involved  |                         |
| in a wildland or prescribed fire accident. |                         |
| The following questions important:         |                         |
|                                            |                         |
| -   Did the firefighter(s) use full PPE?   |                         |
|                                            |                         |
| -   Did the firefighter(s) remove any of   |                         |
|     the PPE or use it improperly?          |                         |
|                                            |                         |
| -   Were Fire Shelters used?               |                         |
|                                            |                         |
| -   What procedures were used?             |                         |
|                                            |                         |
| Analysis of Personal Protective Equipment  |                         |
| (PPE) should be inspected for compliance   |                         |
| with agency 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.                                 |                         |
|                                            |                         |
| PPE standards for wildland fire are found  |                         |
| in the Interagency Fire and Fire Aviation  |                         |
| Operations handbook (Red Book), chapter 7  |                         |
| (USB flash drive). Not all PPE meet the    |                         |
| NFPA 1977 Standards (e.g., wildland fire   |                         |
| boots).                                    |                         |
|                                            |                         |
| Clothing and equipment 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 the burned equipment with the |                         |
| design standard can often help determine   |                         |
| the survivability of a fire-related        |                         |
| accident.                                  |                         |
|                                            |                         |
| Handout 9-3 Personal Protective Equipment  |                         |
| Assessment will provide you additional     |                         |
| information when gathering PPE evidence.   |                         |
|                                            |                         |
| **ACTIVITIES AT THE ACCIDENT               |                         |
| SITE(continued)**                          |                         |
|                                            |                         |
| **Note: Having an equipment specialist     |                         |
| from the Missoula Technology and           |                         |
| Development Center as a Technical          |                         |
| Specialist for the team can be a very      |                         |
| valuable asset. Contact your respective    |                         |
| agency's Fire and Aviation Safety Manager  |                         |
| to request MTDC assistance.**              |                         |
|                                            |                         |
| **DOCUMENTATION**                          |                         |
|                                            |                         |
| The following are types of documents that  |                         |
| should be collected for Wildland Fire      |                         |
| Accident Investigations if available:      |                         |
|                                            |                         |
| -   Dispatch logs and any recording of     |                         |
|     radio traffic                          |                         |
|                                            |                         |
| -   Unit Logs (ICS-214)                    |                         |
|                                            |                         |
| -   Incident Action Plans                  |                         |
|                                            |                         |
| -   LCES analysis (ICS 215A)               |                         |
|                                            |                         |
| -   Agency Land Use Plans                  |                         |
|                                            |                         |
| -   Fire Management Plans                  |                         |
|                                            |                         |
| -   Prescribed Burn Plans                  |                         |
|                                            |                         |
| -   Contingency Plans                      |                         |
|                                            |                         |
| -   Approved Wildfire Situation Analyses   |                         |
|     (WFSA) or Wildland Fire Implementation |                         |
|     Plan (WFIP)                            |                         |
|                                            |                         |
| -   Official reports of Weather forecasts, |                         |
|     Red Flag Warnings & Fire Behavior      |                         |
|     Forecasts                              |                         |
|                                            |                         |
| **DOCUMENTATION (continued)**              |                         |
|                                            |                         |
| -   Training and Qualifications (Wildland  |                         |
|     Fire and Prescribed Fire)              |                         |
|                                            |                         |
| -   Documentation of Work/Rest Guidelines  |                         |
|                                            |                         |
| -   Fire Complexity Analysis /Prescribe    |                         |
|     Fire Complexity Analysis               |                         |
|                                            |                         |
| -   Documented NWCG Risk Management        |                         |
|     Process                                |                         |
|                                            |                         |
| -   Incident Organizer (generally for Type |                         |
|     4 or Type 3 incidents)                 |                         |
|                                            |                         |
| **FIREFIGHTER AUTOPSY PROTOCOL**           |                         |
|                                            |                         |
| As we previously discuss in Lesson 6,      |                         |
| autopsies are critical in establishing the |                         |
| cause of death. This is especially         |                         |
| important for wildland fire line of duty   |                         |
| deaths.                                    |                         |
|                                            |                         |
| The U.S. Fire Administration's Firefighter |                         |
| Autopsy Protocols specifies procedures for |                         |
| the medical examiner/coroner to follow for |                         |
| fire related line of duty deaths.          |                         |
|                                            |                         |
| http://www.usfa.dhs.gov/downloads/pdf/pub  |                         |
| lications/firefighter_autopsy_protocol.pdf |                         |
|                                            |                         |
| **The Chief Investigator should refer      |                         |
| medical examiner/coroner to this           |                         |
| protocol.**                                |                         |
+--------------------------------------------+-------------------------+