CDF Helitack Crew 404 Burnover Accident Investigation Report Tuolumne Fire CA-STF-2191

184 Pages·2005·5.62 MB·English

Accident
Investigation Report
CDF HELITACK CREW 404 BURNOVER
Tuolumne Fire
CA-STF-2191
Stanislaus National Forest
September 12, 2004
United States California
Department of Department
Agriculture of Forestry and
Forest Service Fire Protection
CDF Helitack Crew 404 Burnover
Accident Investigation Report
Tuolumne Fire
CA-STF-2191
Stanislaus National Forest
September 12, 2004
This document contains materials for internal agency use only and
may not be released under the freedom of information act without agency legal counsel review.
1 Report approved by Board of Review May 11, 2005.
CDF Helitack Crew 404 Burnover
Accident Investigation Report
Investigation team leaders:
John D. Berry, Forest Supervisor Date
Eldorado National Forest, Placerville, CA
Dan Turner, Chief Date
California Department of Forestry and Fire Protection, San Luis Obispo
Investigation chief investigators:
Mike Cole, Battalion Chief, CDF-San Luis Obispo
David Edgar, USFS Forest Safety Officer, San Bernardino National Forest
Investigation team members:
Alan Carlson, Battalion Chief, CDF Tehama-Glenn
Jim Engel, Battalion Chief, CDF Butte
Larry Hood, USFS Region 5 Fire Planning Specialist
Craig Kincaid, Fire Captain, CDF Lassen-Modoc
Ted Mathiesen, USFS Helitack Superintendent, Los Padres National Forest
Rhonda Myers, Battalion Chief, CDF Madera-Mariposa-Merced
Denny OʼNeil, Fire Captain, CDF San Luis Obispo
Lynda Philipp, USFS Special Uses, Eldorado National Forest
Chuck Schoendienst, Division Chief, CDF Tehama-Glenn
Peter Tolosano, USFS Region 5 Fire Operations Safety Officer
Robert Van Wormer, Battalion Chief, CDF Santa Clara
Investigation technical consultants:
Brenda Graham, USFS Wildland Fire Meteorologist, Redding, CA
Dave Poucher, USFS Region 5 Health and Safety Program Manager
Chuck Lawshe, CDF (Retired) Scene Investigator
2 Report approved by Board of Review May 11, 2005.
CDF Helitack Crew 404 Burnover
Table of Contents
Maps & Diagrams _______________________________________4
Site Photographs _______________________________________16
Executive Summary ____________________________________24
Accident Review Team Process ___________________________30
Overview of the Accident ________________________________34
Sequence of Events ____________________________________47
Findings ______________________________________________59
Causal Factors _________________________________________70
Contributory Factors ____________________________________77
Non-related Safety Factors _______________________________88
Appendices ___________________________________________94
A. Injuries ...........................................................................96
B. Personal Protective Equipment (PPE) ........................99
C. Experience, Training, Qualifications ........................101
D. Fire Environment ........................................................105
E. Fire Behavior ..............................................................118
F. Fire Behavior Modeling ..............................................123
G. Fire Behavior Conclusions ........................................128
H. Site Examination ........................................................131
I. Downhill Line Construction Review .........................154
J. 10 Standard Firefighting Orders ...............................157
K. 18 Situations That Shout “Watch Out” .....................162
L. LCES Review ..............................................................165
M. California OSHA Findings .........................................168
M. CDF Blue Sheet/USFS 24-hour Report .....................170
O. CDF Green Sheet/USFS 72-hour Report ..................174
Sketch 1
Sketch 2
Sketch 3
3 Report approved by Board of Review May 11, 2005.
Maps and Diagrams
4 Report approved by Board of Review May 11, 2005.
Maps and Diagrams
Vicinity Map _____________________________________________6
Site Location Map ________________________________________7
Travel Route Map ________________________________________8
Fire History Map _________________________________________9
Fire Progression Map Overview ____________________________10
Detailed Fire Progression _________________________________11
Planned Fire Line Construction _____________________________12
Fire Line Construction Prior to Flareup _______________________13
Personnel Locations Prior to Flareup ________________________14
Post Flareup Personnel Locations ___________________________15
5 Report approved by Board of Review May 11, 2005.
Sequence of Events in CMharposn oalnodg iDcaial gOrradmesr
CDF Helitack Crew 404 Burnover
Vicinity Map
6 Report approved by Board of Review May 11, 2005.
Sequence of Events in CMharposn oalnodg iDcaial gOrradmesr
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7 Report approved by Board of Review May 11, 2005.
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8 Report approved by Board of Review May 11, 2005.
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9 Report approved by Board of Review May 11, 2005.