caldwell fire - facilitated learning analysis
TRANSCRIPT
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Caldwell Fire - Facilitated Learning Analysis
Risk Perspective and Medical Response
Initial attack resources faced active fire driven by receptive fuels and multiple thunderstorm cells. Unsecured drip torches and fuel cans were shuttled in the back of a pickup to support a firing operation. Conditions changed causing a change in strategy
necessitating the repositioning of resources back through the fire area. Fire pulsed along the road and smoke obscured visibility. The occupants of the truck discovered the
fuel in the bed of the pickup had caught fire. While unloading the volatile cargo a firefighter suffered a second degree burn to one leg after his pant leg caught fire.
Lava Beds National Monument, July 22, 2020
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Contents:
Background & Operating Theater: Lava Beds National Monument
The Story: A New Start in the Park
Tactics Unfold
Storm Cells!
Event Timeline
Prepare to Defend Headquarters
The Fuel Catches Fire!
Response to the Injury
Lessons to Apply from the Participants
Observations made during participant interviews
Regarding Tactical Decisions and Risk Assessments
Regarding Leadership and Intent
Regarding the Medical Report and Response
Analysis, Notes & Recommendations from the FLA Team Modoc Interagency Fire Alliance (MIFA) performs well
Interdisciplinary support at Lava Beds is commendable
Stowage of fuel during transportation
It’s not about “Right” or “Wrong”- Perspectives on Risk are subjective
Standardized and Ritualized Response and Reporting of Incident-within-Incidents
Appendix
PPE report from National Technology Development Program
Additional Pictures/Video
Facilitated Learning Analysis Team: Chad Fisher – NPS, Wildland Fire Operations Program Leader, NIFC
Kevin Killian – NPS, Chief Ranger, Yosemite NP
Tom Garcia – NPS, Deputy Regional Fuels FMO, Pacific West Region
Jen Rabuck – NPS, Safety Specialist, NIFC
Kathy Komatz – NPS, Training Specialist, NIFC
A special thanks to all the FLA participants for sharing their stories and
perspectives towards the common goal of learning and organizational growth.
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Background and Operating Theater:
Lava Beds National Monument Lava Beds National Monument is located in northeastern California near the town of Tulelake. It
is a land of turmoil, both geological and historical. Over the last half-million years, volcanic
eruptions on the Medicine Lake shield volcano have created a rugged landscape dotted with
diverse volcanic features. More than 800 caves, Native American rock art sites, historic
battlefields and campsites, and a high desert wilderness can be found within the monument. The
National Park Service unit is bordered on three sides by the Modoc National Forest, managed by
the US Forest Service, and the fourth boundary is shared with the Tule Lake National Wildlife
Refuge, managed by the US Fish and Wildlife Service.
All three agencies have independent wildland fire programs but budget reductions in the mid-
2010s reduced the monument’s wildland fire response capability. Working relationships between
the three federal land management units have been good but budget reductions have compelled
an even stronger partnership and collaboration in recent years. This was formally solidified
through the creation of the Modoc Interagency Fire Alliance (MIFA) Operating Plan, which was
signed by all partners on July 2, 2019. The MIFA Operating Plan primarily serves to more
efficiently provide Fire Duty Officer (DO) coverage across the large geographic area of shared
responsibility. Additionally, this plan provides a framework under which the partners can utilize
available personnel and resources across bureau/agency lines to maximize the interagency
efficiency and effectiveness without necessitating the exchange of funds. This plan includes
a formal Delegation of Authority from Alliance Line Officers to both Alliance DO and Type 3, 4
and 5 Alliance Incident Commanders.
The national monument also relies on collateral duty, or militia, firefighters and support. The
Maintenance Division consistently provides multiple employees that assist in wildland fire
response in roles ranging from water tender driver, engine boss, and base camp manager, to
Incident Commander Type 5 (ICT5). This intra-park support is a critical component of the
monument’s wildland fire program and contributes to the national effort as well as local Alliance
efforts.
In the third week of July 2020, environmental conditions in
Lava Beds National Monument were dry. In fact, it was in
an area of Severe Drought classification on both the Palmer
Drought Index and U.S. Drought Monitor Index. The total
precipitation percentile for the water year, measured from
October 1, 2019, through June 31, 2020, was at the 10th
percentile. At Indian Well RAWS, located approximately
two miles from the start of the Caldwell Fire, the energy
release component (ERC) was just under the 90th percentile.
Local representative fuel moisture values for silver sagebrush and desert bitterbrush were at or
below historic low values for the time of year. The documented fire danger for the area was
“Very High.”
“I had just run the indices comparing
the July Complex/Caldwell Fire and
the Frog Fire. We were at or above the
levels of the Frog.”
Dispatch Center Manager
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Below: US Drought Monitor Map released July 30, 2020, for California showing significant departures from normal. Right: Hourly Weather Recordings from the Indian Wells Weather Station on 7/22/20. The grey shading indicates 15:30.
The Story:
A New Start in the Park On the evening of July 21st, thunderstorms moved through the area. At 18:50 the Schonchin
Butte Lookout, located within Lava Beds National Monument, recorded a lightning strike in the
South Caldwell Butte area. Light precipitation accompanied the lightning strike.
On the morning of July 22, a small resource management crew was working in the vicinity of
Caldwell Butte and smelled smoke but didn’t see any further indication of a fire. At 10:51 on
July 22, the Timber Mountain Lookout on the Modoc National Forest reported a smoke in the
Caldwell Butte area to Modoc Interagency Communications Center (MICC), located in Alturas,
California. Coincidentally, the individual staffing at Timber Mountain on the 22nd was the same
person at the Schonchin Butte on the 21st.
When he heard the smoke report, a Lava Beds National Monument militia firefighter and
qualified Incident Commander Type 5 (ICT5) and Incident Commander Type 4 trainee, referred
to hereafter as Lava-1, got in his truck and drove down the 10 Road toward Caldwell Butte. His
intent at the time was to see if he could get information on the fire to provide to the MIFA DO.
He had planned to telework but decided to come into the office given the weather and lightning
the previous day. His instincts told him it would be best to be in the monument and available.
Dispatch logs show Lava-1 provided a report on conditions and assumed the role of ICT5 at
11:24. The initial report to Dispatch stated that the fire was three acres with a moderate rate of
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spread in grass, juniper, and timber. There
was no wind on the fire at the time, clear
skies overhead, and the fire was estimated to
be 1.5 miles from the road. Broken terrain
and fuels in the area made getting to the fire
difficult.
The area was operating in what is known as
a Lightning Plan: meaning that due to the
expected amount of initial attack activity
after the lightning the day before, the normal
run card resources that would be dispatched
to a fire had been reduced. In fact, there
were numerous other fires in the MIFA on
July 22nd, particularly on the Modoc
National Forest. Since the Lightning Plan was in effect, the normal dispatch of 7 engines, 2
crews, 2 dozers, 2 water tenders, 1 Battalion/ICT3, 1 Patrol Truck, 1 Fireline Resource Advisor
(REAF), 1 Type 2 helicopter with crew and 2 air tankers for a High indices dispatch was
reduced. The following resources responded: a patrol truck (Patrol-1), a Modoc Type 3 engine
(Engine-1) with a chase or utility truck (Chase-1), and a Fish and Wildlife Service Type 3
engine (Engine-2) led by a monument collateral duty firefighter qualified as engine boss. This
was the first shift the NPS employee had worked with the refuge employees on Engine-2. They
took time that morning to discuss their unfamiliarity with each other and how they would take
that into consideration if they got an assignment.
Patrol-1 was the next resource to arrive on scene
at 11:28 and met with Lava-1 to discuss the
situation and plan. He left his truck and hiked
into the fire to scout. He reported back to Lava-1
that the fire was approximately four acres with
intermittent torching. He didn’t consider fire
behavior to be extreme, but it was generally more
active than what is typical. Other incident
resources reported similar observations when
they arrived at the fire. Soon after Patrol-1’s
arrival, Timber Mountain Lookout called to
advise them of thunderstorm buildup in the area.
Patrol-1 and Lava-1 pulled out of the area to the junction of the 10 Road and Tichnor Road
(hereafter called Staging) to develop a plan.
Lava-1, in consultation with Patrol-1, decided to burn along the 10 Road in a southeasterly
direction to contain the fire using the 10 Road, Tichnor Road, and a system of old roads and
trails (FS22D Spur and Caldwell Ice Cave Trail). This decision was based on the forecast,
challenging lava terrain, and the fact that this area had a limited fire history with heavier than
normal fuel loading. The plan included the use of aerial support to help slow fire spread in
conjunction with firing out the road working downhill (See map Caldwell Fire Tactical Plan).
12:18 – View of the fire and fuels from the 10 Road. Note the storm cell building in the background.
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Operations were planned to begin on the Tichnor Road (south side of the fire) based on initial
observed spread and fire behavior.
Around noon Engine-2, Engine-1, Chase-1, and a Lava
Beds National Monument water tender, Tender-1, staffed
with two collateral duty monument employees, were on
scene. An Air Attack platform (AA50) was on scene at
12:11. Additionally, Helicopter-502, Tanker 96 (a Cal Fire
S2), and a single engine airtanker (SEAT), T-805, were
assigned and began water and retardant drops.
By 12:15 the MIFA DO was on scene as well. He
cautioned all resources to think about the fuels and terrain between them and the fire and to
consider what could happen if they were caught off the road when predicted thunderstorms
arrived. The DO ordered an Incident Commander Type 3 (ICT3) and one was en route at 13:03.
“The fire was out a ways – we
weren’t able to go direct especially
with those cells predicted – it wasn’t
safe to go in on it.”
Tender-1
Tactics Unfold At 13:15 the DO released all aircraft from the Caldwell Fire to the Allen Fire as a higher priority.
The aerial resources worked the Caldwell Fire from approximately 12:11 to 13:24.
Meanwhile, Lava-1 asked Patrol-1 to go to
monument headquarters and pick up drip torches
and mixed burn fuel. Given the interagency nature
of MIFA, Patrol-1 had worked out of the building
in the past and knew where the fuel was stored in
hazardous materials lockers. He retrieved five
jerry cans and ten drip torches. The jerry cans were
military-style cans retrofitted with a self-
closing/retractable lid. Upon his return Patrol-1
asked Lava-1 if he should keep the fuel in his
truck and bump it along for the ignitors or if he
should transfer it to Lava-1’s truck, an open bed
Ford F-350, so he could serve as the northern
lookout. The decision was made to move the fuel
to Lava-1’s truck (Truck-1) and have Lava-2, the militia firefighter assigned as rider from
Tender-1, drive truck Truck-1. A firefighter from Engine-1 who was working on his firefighter
type 1 (FFT1) task book joined Tender-1 and was assigned to southern lookout duties.
The ICT3 arrived at 14:51 and saw Lava-1, who informed him of the plan to burn from the 10
Road. He stopped at the monument headquarters to meet with the DO, monument
superintendent, and other monument fire staff, then he assumed command of the fire. All the
resources knew he was there and that he was now the Incident Commander, but no official notice
was broadcast over the radio. Lava-1, who is a qualified ICT4 trainee, began referring to himself
as the IC trainee and self-assumed that role. The ICT3 considered him to be in the role of Firing
Boss. Other resources on scene thought he was in the ICT4 trainee role. Regardless, resources
15:01 - Initial attack resources work to defend the main park road with a burnout during the Caldwell Fire.
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were briefed on the operation and lines of communication were clear. The ICT3 drove past the
engines to the south end of the fire to get a better view and scout options.
After what seemed like long delays in getting started, firing operations began around 14:52 in a
northwest to southeast (topographically downhill) direction toward the monument boundary and
ultimately toward Staging. Engine-1 conducted the firing operation while Engine-2 was holding
the road. Tender-1 remained staged in a safe location near the park boundary away from the
firing operation to the east/southeast along the 10 Road. Initial observation of the firing
operations indicate that it was progressing well, drawing in from the road toward the main fire. A
few spot fires were picked up on the opposite side of the road as the firing progressed but were
not considered to be exceedingly problematic or of significance to firefighter safety and
operational success. Tender-1 drove along the 10 Road using the spray bar to cool the fire’s edge
behind the burners. He turned the Tender and made a second pass on his way back toward
Staging.
Storm Cells! By 15:30, firing had progressed roughly 200-400 yards when it was halted (distances vary
between participants). Another thunder cell over the area with elevated winds of 30-40 mph
reported, and a shift in wind direction caused the fire activity to pick up rapidly and push hard in
an east/southeast direction toward and ahead of the firing. Engine-1’s Captain never felt
uncomfortable, but recalls things starting to change and getting the feeling like the hair was
standing up on the back of his neck. The ICT3 heard radio traffic about a wind shift and called to
confirm people were heads-up and had escape routes.
Tender-1was now serving as a lookout near the monument boundary. He observed an increase in
fire behavior and spread moving in his direction. He called to tell the ICT3 and it turned out the
ICT3 had just pulled up behind the tender. The two of them backed away and the ICT3 had all
resources withdraw to Staging. All resources except for Patrol-1 (serving as lookout at the north
“Firing was going great – we were building a real nice catcher’s mitt before the wind
happened – literally in a minute. We had no issues on the road before that wind.”
Patrol-1
15:36 - Fire behavior exhibited during strong southeast push over the 10 Road influenced by thunderstorm. The burnout operation was halted, and resources pulled back to Staging.
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end of the firing operation) and Lava-2 driving Truck-1withdrew to this location. Patrol-1 and
Lava-2 moved their trucks to the northwest along the 10 Road, further from where the fire was
actively pushing over the road. They also moved Chase-1 back by leapfrogging it and truck
Truck-1.
The ICT3 met Lava-1 near Staging. Lava-1 got in the ICT3’s truck and they waited until fire
behavior moderated before driving through to the north end. Lava-1 got out at his truck, Truck-1,
and got in the passenger side. Lava-2 drove them back down the road to Staging. The ICT3
continued to monument headquarters to brief the superintendent on the thunderstorms, fire
activity, and their inability to catch the fire. Engine-1 drove to the north end of the fire, picked
up Chase-1, and drove back to
Staging. While there, Engine-1’s
crewmembers refilled drip torches
using jerry cans from truck Truck-
1. The jerry cans were awkward to
use, and no nozzles were
available. Engine-1’s FFT1
trainee who was working with
Tender-1 returned to Engine-1.
The ICT3 returned to Staging and
then drove south on the Tichnor
Road scouting options. Upon his
return to Staging, he met with the
engines and the DO, who
informed him an Incident
Management Team (IMT) was on
order to manage multiple fires in
the area.
The dispatch log indicates the
ICT3 contacted MICC at 15:52.
MICC made the following note:
“Caldwell is off and running. It’s
going to IMT. 500-700 acres.
Hard winds. Pushing to the east.”
The dispatch log has an entry one
hour later at 16:51 with a report
from the DO that the fire was
estimated at approximately 1,000
acres and moving to within eight
miles of the community of
Tionesta to the east/southeast. A
level 2 evacuation of Tionesta was
requested. In addition, WAPA KV
Caldwell Fire Initial Attack Timeline
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powerlines, a gas pipeline, and the BNSF Railroad line were being threatened.
Prepare to Defend Headquarters Between 17:00 and 17:44 the fire continued to grow with northwest flanking and east/northeast
finger runs advancing in the direction of Patrol-1’s lookout position. Fire was crossing the 10
Road to the northeast. The ICT3 contacted Lava-1 to move to the north end of the fire along the
10 Road to be ready to protect headquarters.
The message to move north was relayed to Engine-1, Engine-2, and Chase-1 by Lava-1, however
no specific reason or assignment was given at that time. Tender-1 stayed at Staging.
As the resources departed Staging, Lava-1 led in truck Truck-1 with Lava-2 driving, Engine-2
was next, then Engine-1, and Chase-1 was in the rear. There was active fire behavior along the
road and the ICT3 recalls hearing radio traffic about the road being a bit hot. Lava-1 advised
resources to move through ‘using their own caution.’ The procession of vehicles began to stretch
out somewhat as individual vehicles would stop to allow smoke to clear off the road or pulses of
fire to calm. Eventually Engine-2 decided to stop and turn around given the fire behavior.
Engine-1 and Chase-1 bumped past Engine-2 to continue. Ultimately the smoke became too
thick and Engine-1 and Chase-1 turned around in the road and went back to Staging.
Meanwhile, Patrol-1 was observing the situation from the north end of the fire and called Lava-1
to tell him it wasn’t a good idea to come through - the fire was pulsing against the road and
visibility was variable. Lava-2 (driving Truck-1) could see Patrol-1’s headlights ahead through
the smoke. There was fire on both sides of the road, “little fires” getting bigger closer to Patrol-1.
It was really smoky and there were flames over the road. Lava-2 checked his rearview mirror and
saw fire and smoke behind. Lava-2 paused as he assessed: he didn’t feel like he is good at
backing up particularly with smoke on the road and engines behind him; Lava-1 confirmed it
was okay to keep going. Lava-2 estimates that it was 40 yards through the fire and smoke, and
since he could see Patrol-1’s headlights, he wasn’t uncomfortable especially with Lava-1’s
reassurance. He knew they could make it through and Lava-2’s largest concern was the fuel
containers in the truck bed becoming an issue. Lava-1 later stated that he had simply forgotten
about the fuel in the bed.
The Fuel Catches Fire!
Lava-2 drove past Patrol-1 in order to keep the road open and not be close to Patrol-1 in case the
fuel had indeed caught fire. Patrol-1 did not see any fire in the back of Truck-1 as it passed him.
Lava-2 had been involved in a previous (off work)
car fire and instinct told him to check the fuel in the
bed of the truck. Both he and Lava-1 got out of the
truck and looked over the bed rail. The fuel cans had
become somewhat disheveled and strewn about the
back of the truck due to being unsecured and Lava-1
could see one container spitting fire and it seemed to
be venting around the pull handle. Lava-1 reacted by
climbing into the bed of the truck over the tailgate,
“Instinct made me think we should
check the load in the back of the
truck – I knew we were okay, but we
may need to ditch the truck if that
fuel had caught fire.”
Lava-2
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telling Lava-2 to get gloves. While Lava-2 went to grab gloves, Lava-1 began throwing jerry cans
and drip torches off the back of the truck over the passenger side tailgate corner. By then Lava-2
was back and attempted to drop the tailgate but couldn’t because of an automatic locking system
in the truck. Lava-2 lifted 1-2 jerry cans up and over the tailgate before he noticed flames on
Lava-1’s pant leg. He yelled at him to stop, drop, and roll, and ran to the front of the truck to get a
fire extinguisher. Lava Beds has a standard operating procedure that all their vehicles have an
extinguisher. Lava-2 grabbed the extinguisher, planning to use it on Lava-1. Lava-1 had climbed
out of the truck, dropped onto the pavement and rolled to extinguish the flames on his left pant
leg. Rolling on the pavement didn’t work, so he stood up, stepped to the road shoulder and rolled
in the dirt, finally extinguishing the fire.
Seeing that Lava-1 was no longer on fire, Lava-2
turned with the extinguisher and began spraying
the fire in the truck bed and under the right rear
area behind the tire. He was successful in putting
the fire out. Patrol-1 recalls looking in his mirror
and seeing fire on the pavement and thinking,
“Whoa! What?,” so he got out of his truck and
walked over to see what was happening. When
the jerry cans and drip torches were thrown out
of Truck-1, a fire was started in the roadside
fuels and on the pavement, which ultimately
burned the rear passenger side corner of the
truck, bubbling the paint and melting the brake
light lens. Further damage was done to the right
side of the bumper as fuel from the bed of the
truck, likely from tipped jerry cans, drained
under the tailgate catching fire along the way.
Response to the Injury At this point, Lava-1 went back to normal radio operations. The ICT3 recalls hearing some
traffic where an engine asked if they needed anything and the reply was, “No, just water,” and he
didn’t hear anything further. Engine-2 recalls the conversation about water and remembers
thinking Lava-1’s voice seemed a bit out of breath, which was uncharacteristic for him. A few
minutes later Lava-2 overheard Lava-1 say on a phone call that he’d burned his leg and didn’t
want to take his boot off. It’s likely this call was with the DO. This got Lava-2’s attention and he
had Lava-1 go to the back of the truck and sit on the tailgate. It seems the adrenaline began to
wear off, and Lava-1 was becoming sensitive to the pain. Lava-1 is an experienced EMS
provider working on a local volunteer service and coordinator of the monument’s EMS program.
He gave Lava-2 instructions on how to care for the burn. They removed his boot, cooled the burn
with water, and wrapped it with a dry cloth.
Given Lava-1’s knowledge of the local EMS system, he told the DO he was going to call an
ambulance. The DO reminded him that to get medical assistance on a fire he should go through
MICC. Resources on the fire heard Lava-1 call MICC and report a burn injury, he then used
local frequencies to request an ambulance. Lava-1 did not use the Medical Incident Report
Damage inside the bed of TRUCK-1 after the fuel caught fire. Note the charring in the bed channels and wheel well and the melted toolbox.
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(commonly called an 8-Line) found in the Incident Response Pocket Guide and in the MIFA
Incident Organizer, nor did MICC ask for the information in the Medical Incident Report. The
ICT3 didn’t hear this radio traffic. Resources report that radio traffic was heavy, particularly on
the Command frequency, given the number of fires and activity that day and that there had been
times where Lava-1 had tried to contact the ICT3 but wasn’t able to make contact for periods of
time throughout the day.
After receiving the phone call from
Lava-1 that he had been burned, the
DO called the monument
superintendent to let him know.
The monument superintendent in
turn called the Administrative
Officer (AO) at 1755. The AO sent
a text to the ICT3 at 1757 that she
would be able to cover OWCP
needs for the burn patient. This was
the first notification the ICT3 had
of a burn on the fire and he was
understandably surprised.
Resources report that the ICT3
called Lava-1 “almost
immediately” after Lava-1 called
MICC. At 1759 the AO called the
ICT3 and while on speaker phone
overheard the ICT3 and Lava-1 discussing the injury. Various resources overheard the radio
conversation and state the two discussed the severity of the burn and that the burn was from drip
torch fuel and not from the wildfire. Additionally, the communication indicated that the medical
transportation plan was for Lava-2 to drive Lava-1 to a transfer point with an ambulance.
Lava-2 started driving Lava-1 to meet the ambulance. He stopped at park headquarters to ensure
truck Truck-1 was safe to drive before continuing on to meet the ambulance using Truck-1’s
emergency flashers. After about 20 minutes, Lava-2 noticed two vehicles with emergency
flashers pass in the opposite direction. He asked Lava-1 if they might be with the volunteer
ambulance service and Lava-1 didn’t think so. Shortly afterwards they overheard radio traffic
indicating that the responding EMS resources thought they had passed the burn victim going the
other direction and they were going to turn around. Hearing this, Lava-1 pulled off the side of the
road to connect with medical care that arrived soon thereafter.
Lava-1 was transferred to an ambulance and transported to Klamath Falls for medical care.
Lava-2 turned around and began driving back to monument headquarters, stopping to collect
himself before arriving back at the fire.
A Hospital Liaison was assigned and available soon after the incident occurred. Due to
complications with COVID restrictions on individuals allowed at medical centers, and a lack of
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information on the nature of the injury regarding which facility may be treating Lava-1: local
hospital or regional burn center, the Liaison was unable to engage directly with the employee.
The FMO offered to be present at the hospital, particularly once the true extent of the injury
became known and it appeared Lava-1 would be released that night. Lava-1 was released from
the hospital later that evening. Due to misunderstanding and miscommunications, no National
Park Service personnel were present to help with logistics or transport; he was picked up by his
family and taken home that night.
Lessons to Apply from the Participants Hindsight has a way of altering the past – of dulling our thoughts, awareness, and observations
that made perfect sense without the privilege of seeing the future. We know the concept of
Monday Morning Quarterbacking is folly, yet such conversations play out weekly across the
country…
Despite this, and possibly because of it, the FLA team wanted the participants, who best knew
the factors that contributed to their state of mind and their decision process during the event, to
share what they learned and what they personally would consider if they were back in the
moment, responding again to the Caldwell Fire.
Observations made during participant interviews:
Regarding Tactical Decisions and Risk Assessments:
• I’d ask more questions: What’s our mission? My questions can trigger yours and initiate
better communication overall.
• I could have asked the lookout what the conditions were like on his end before I started
driving.
• You need to have common sense – look at the situation and not just take someone’s word
for it – things change in an instant. Use your judgement, take all the information into
consideration, sure. Know it is okay to defy an order – you know your situation best.
• We tote jerry cans all the time – should be thinking about staging them more and take
that into account.
From the perspective of an observer listening as the stories and reflection occurred, none of
these statements are particularly revolutionary. In fact, these might be ordinary things we
hold as truths. We know that communication, situational awareness and having an
accurate perception of the fire ground are vital to our safety and success as firefighters.
Yet how many of us have held back when we had a question about our assignment? How
many of us trusted an observation made by someone else on the fire? Furthermore, how
many of us have transported containers of fuel around a burn unit or a wildfire? Was that
foremost on your mind as you conducted business? Did you just get lucky, or did you
have other mitigations in place to prevent the fuel from catching fire?
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Regarding Leadership and Intent:
• I could give clearer Leader’s Intent from an Agency Administrator’s perspective to my
employees.
• I could have done a more formal transition.
• I could have stayed with the burn longer to insure it was going well. Maybe I’d have been
there when the situation changed.
• We should have started the burnout sooner and we may have beaten the cell to tie it all in.
Again, from the perspective of an observer these statements make perfect sense. We have
been trained to be clear with our intent and to be mindful of transitions. It takes practice
for dynamic situations and we often don’t have time in those moments to prepare succinct
and clear statements, collect feedback, or pause for self-reflection on performance. We all
struggle through each moment, doing the best we can, until we find ourselves in the ring
of a bullseye. It takes a team to make a team: the responsibility to seek understanding, ask
for clarification and pause for even seconds to plan our next steps.
We can’t always fix things, particularly if we don’t know in the moment they are about to
break! Be wary of absolute “findings” when using the benefit of hindsight.
Did you say what you meant? Did you find yourself hedging or being vague for some
reason? Do leaders at all levels have what they need to be successful? Did you ask?
Regarding the Medical Report and Response: • I will always use the MIR and make notification
– regardless of their assessment of the
situation/even if the potential patient tells me it
isn’t bad, or despite how fast things are
happening. Especially with burns – they’re hard
to see compared to other injuries.
• People are not very good at self-assessments when they are the one that is hurt.
• Build in redundancy – especially with no Com Unit in place – to ensure the IC is aware
of ongoing IWIs.
No one wants to have to manage an unexpected event in the middle of a fire. Most of us hope
someone else will be there to step up if one were to occur. Our jobs have inherent risks
that can’t be completely removed, so it is part of our responsibility to be prepared for
WHEN an IWI may happen. Recognize that systems are there to support success and
serve as a framework, but they can’t give us all the answers. IWIs take practice and the
more we anticipate the rough spots, the easier it will be to react in real life. We train and
reflect on past performance to help us grow, and this is no different.
“He told me he was burned – not
that he needed an ambulance.”
DO
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Ask yourself each shift: “Where is a copy of the 8-Line?” Take a breath and then move one
step at a time: What are the knowns about the situation? What are the unknowns? What
is your biggest concern about an injured/sick person? What support do I have and what
do I need?
Analysis, Notes & Recommendations from the FLA Team
Modoc Interagency Fire Alliance (MIFA) performs well The creation of the MIFA, signed by all partners in 2019, served the interagency community
well. The formal Delegation of Authority from Alliance Line Officers to Type 3, 4 and 5
Alliance Incident Commanders across the large geographic area of shared responsibility
facilitated rapid response at the appropriate management level. MIFA also enabled effective
utilization of available suppression personnel and resources from across bureau/agency lines.
Seamless cooperation was clearly evident during the initial shift on the Caldwell Fire. Not only
did a USFS IC3 arrive to provide leadership on an evolving NPS incident, but resources from all
three agencies worked together during suppression efforts. Initial resources included a NPS
water tender, a USFS Type 3 engine and Patrol Truck and a FWS Type 3 engine staffed with a
NPS engine boss. The initial IC was a NPS maintenance employee with collateral duty wildfire
qualifications. He provided leadership to interagency employees, many of whom were full-time
fire personnel. During the interviews, participants commented on their previous experience
working with the other Caldwell Fire responders on past events. This familiarity was helpful in
their efforts.
Interdisciplinary support at Lava Beds is commendable The national monument relies on collateral duty, or militia, firefighters and support. The
Maintenance Division consistently provides multiple employees that assist in wildland fire
response in roles ranging from water tender driver, engine boss, and base camp manager, to
Incident Commander Type 5 (ICT5). This intra-park support is a critical component of the
monument’s wildland fire program and contributes to the national effort as well as local Alliance
efforts.
Critical interdisciplinary employees on this fire included the initial ICT5, the tender driver and
rider, and an engine boss that was staffing on a FWS responding engine.
Stowage of fuel during transportation The number and configuration of fuel containers
involved in this incident could not be accurately
pinpointed by the review team. Originally there were
ten drip torches and five jerry cans full of fuel
transported to the site specifically for the firing
operation. Estimates are three to eight torches and three
to six jerry cans may have been in the back of the truck
“No one likes those cans – they’re
leaky, they dribble, and you can’t stop
them cleanly. They’re damn awkward
to use and they make a mess.”
Tender-1
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at the time the fuel caught fire. It is suspected that additional containers may have been added to
Truck-1 during the burnout operation from an engine. A least one torch completely melted after
being tossed from the truck. Other equipment that was undamaged may have been returned to
service and reintegrated into the supplies in the hazmat storage lockers. We accounted for two
damaged torches and three damaged jerry cans at a minimum.
The use of the maintenance vehicle for fire operations was a spontaneous decision. The supplies
were quickly transferred to the pickup from Patrol-1 and shuttled around the fire to support
operations. During this time, the cargo was not secured and Lava-1 and Lava-2 noted that the
cans were somewhat disheveled and strewn about the back of the truck when they stopped to
assess their status after driving past Patrol-1.
FLA team members filmed a reenactment using similar empty containers. Cans were loaded into
truck Truck-1 and driven 200 yards to the injury site. During transit, the containers shifted
considerably and were found rolling around in the bed, some fully
tipped on their sides.
Additionally, tests were conducted transferring fuel from these
jerry cans into a drip torch, without a spout since there were none
available that day. We also tested leakage on several jerry cans by
tipping them over when full, and half full, to see anticipated
spillage rates. In all cases, fuel was found to leak out, coat the
outside of the containers, and pool around the container openings.
A Fire Investigator specializing in wildland fire situations
reviewed photos of the truck, fuel cans and burn patterns after the
event. He found clear evidence of significant torch fuel in the bed
of the pickup that aligned with spillage from unsecured cans.
There was not enough evidence to distinguish an ignition source
(direct flame impingement or a fire brand), but evidence did rule
out radiant heat as the cause of the fire. Burn patterns also indicate
the truck had been situated with the passenger rear corner slightly
lower than the rest of the vehicle, allowing fuel to run out of the
bed via the tailgate crack, onto the bumper and subsequently under the vehicle. See Appendix
for additional photos.
The military-style metal jerry cans used to transport fuel had been retrofitted with the self-
closing lids as required by policy and PMS-442 (2019 NWCG Standards for Transporting Fuel,
refer to pages 8-9).
The drip torches involved did not meet DOT specifications (UN 381, UN 1B1, UN 3A1) or
Forest Service specifications 5100-614, effective in June 2019. While not necessarily a
contributing factor, it is worth noting that these torches need to be removed from further service
(see PMS-442, pages 14, 31).
Per PMS-442, pages 33-34 and 40, fuel containers, drip torches and jerry cans, must be secured
for transport in an upright position in a crate, box or rack. All vents are to be closed, nozzles or
Damaged military-style jerry cans used on the Caldwell Fire that were recovered after the IWI.
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spouts should be removed. Bung covers should be replaced securely and all excess fuel from the
outside of the container should be wiped away.
Recommendation: Inspect all fuel containers currently in use to insure they meet policy and
specifications. Remove any drip torches or jerry cans that are not compliant.
Recommendation: Any time fuel is being transported, ensure that it is secured in an upright
fashion to reduce chances of fuel spillage. Consider carrying hazmat pads to facilitate spill
cleanup, should it occur during use.
It’s not about “Right” or “Wrong”- Perspectives on Risk are Subjective Risk perception and tolerance are highly personal. Past experiences and unique situations can
elicit variable levels of awareness, sensitivity and reactions from one person to the next. This
directly validates why effective communication is a foundational element of wildland fire
planning, engagement and ongoing operations. It is the primary and most comprehensive way to
bring together the diversity of risk perceptions and tolerances into a collective awareness,
context, and understanding with the shared goal of informing a consistent and appropriately
thought out risk-based approach and response to a wildland fire situation.
On the Caldwell Fire, perceptions of risk were effectively acknowledged and shared,
demonstrated by the individual and group briefings throughout the IA. The acknowledgement of
the elevated risk of direct attack resulted in the development of a reasonable and safe indirect
plan - firing out the road with established safety zones and escape routes, lookouts monitoring
conditions, and effective communications. This plan was based on commonly observed and
communicated fire environment risks associated with elevated fire behavior, in relatively heavy
fuels, having fire established well away from the road in very rough terrain, and expected
thunderstorms over the area.
Another well-informed risk decision was made to remove the resources from the firing operation
to a safe staging area due to extreme fire behavior induced by thunderstorms that pushed the fire
over the 10 Road, nullifying the original containment plan.
In contrast, a later decision moved resources from a position of relatively low risk in the staging
area back through an area of active fire, dense smoke, and other potential hazards to get to the
other side of the incident. Most resources had a notion that they were repositioning due to the fire
spreading and potentially threatening the park headquarters located a couple miles north.
However, FLA Team observations and inquiry determined that no single individual resource was
clear on why they were repositioning, the urgency to move, or what the new plan was going to
be. Despite this, resources proceeded back through the fire area with only a vague understanding
of the overall circumstances and mission.
Based on participant statements, they did not have the same perception of the situation and risks
during their individual exposure to the variable areas of active fire and limited visibility along
the road on which they were told to proceed:
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• The Truck-1 vehicle, which was the first in the line of resources, noted these conditions
and conducted an informal risk assessment; the driver (Lava-2) expressed a certain
amount of unease and trepidation in proceeding, while the passenger (Lava-1) perceived
things to be less disconcerting. Ultimately, they made the collective decision to continue.
• The first engine (Engine-2) module also had conversation within their vehicle about
conditions on the road. They decided to turn around and return to Staging due to fire
behavior along the road.
• The other engine (Engine-1) and their chase truck (Chase-1) proceeded past them before
ultimately choosing to go back to the staging area based on their shared concerns with the
poor visibility and dense smoke along the road.
These contrasting perspectives of the same situation validate the significance of making well-
informed risk-based decisions. It is worth noting that no one perspective is “right” or
“wrong.” The value of differing opinions and observations is the resulting conversation and
risk awareness.
Recommendation: It is critical to raise and share our personal perspective and collective
situational awareness, particularly given active fire behavior and in dynamic situations:
• always complete a comprehensive mission brief (request one if not given),
• acquire and evaluate feedback from assigned personnel,
• if you have concerns, communicate them immediately (see something; say something),
• ensure communications are heard and understood,
• utilize sound risk management as a basis for all decisions,
• critically analyze the situation without rushing, go slow to go fast,
• anticipate and adjust to changing conditions,
• trust your instincts and do not neglect implementing established turn down protocols as
necessary.
Standardized and Ritualized Response and Reporting of Incident-within-Incidents Medical incident reporting guidelines within the wildland fire service state that all medical
emergencies shall be reported via radio to dispatch using the Medical Incident Report format
(commonly known as the 8-line). For regular fire employees, this standard method of reporting is
second nature as it is part of every crew’s annual orientation and training. For collateral duty fire
personnel, on the other hand, this method of reporting could be a significant departure from
procedures used by their program or what they would naturally do within the course of their
daily assignments on their home unit.
The value of reporting medical emergencies over the radio with a standardized reporting format
and clear text language comes in the increased situational awareness of all resources on the
incident who hear the report, as well as establishing that there is now an “incident within an
incident” (IWI) and everyone needs to be aware of the potential of an immediate shift in incident
priorities.
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Recommendation: Extra time and attention should be directed during briefings to ensure that all
assigned resources are aware of IWI procedures, Medical Incident Reporting guidelines, and
radio frequency assignments.
Recommendation: Dispatch should ensure that when an IWI is initiated, the IWI is declared to
all incident resources and the IC is notified immediately. In the confusion that accompanies
IWIs, the initial report may not have been heard by everyone who should be aware.
Assigning a Hospital Liaison When an employee is injured, we must expend every effort to get them the care and support they
require as soon as possible. Additionally, that support should continue for the entire duration
employees need it. A Hospital Liaison’s response extends beyond being present at a medical
facility; it includes getting the patient home safely, and can include assisting with potentially
extensive therapy visits, or it may even involve home convalescence. Their role is to serve the
injured employee, and act as an information and support intermediary between the bureau and
the employee, staying within HIPPAA and agency policy guidance.
Recommendation: Formal training can provide for appropriate liaison recruitment, consistent
support skills, and a comprehensive understanding of the Hospital Liaison position and all it may
entail.
Recommendation: Any time an employee is sent to the hospital, a Hospital Liaison should be
identified and assigned. The Liaison should be the patient's advocate but should also ensure that
the Bureau is aware of, and meeting, the patient’s needs within policy limitations.
Of Note: Team’s Learning Related to Extinguishing PPE Fires During the process of putting this report together, we’ve heard a bit of advice on “Best
Management Practices” everyone should know for use in situations where your Nomex pants are
on fire. In this incident, the two people present at the time decided to use the Stop-Drop-Roll
technique. Lava-1 found it wasn’t quite that simple and needed multiple attempts to put the fire
out. Previous RLS or FLA have suggested using gloved hands to “clap” or pinch the effected
portion of fabric. They’ve also cautioned us NOT to smash the burning fabric, and the actual fire
itself, against our skin.
This event has uncovered another option for putting out a pants fire: Unbuckle and remove the
pants down to ankles or below the boot tops. This will reduce flame lengths and remove the heat
from the skin. The fire can then be extinguished away from the legs by pouring water on the
flames or smothering it within the folds of fabric. The attached PPE Report from the National
Technology Development Program (NTDP) also recommends wearing over-the-calf wool blend
socks to further reduce burn injuries to legs. See the Appendix for the full report with a video
link demonstrating suppression options and results: Burning fuel on pants video.
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Appendix: PPE report from National Technology Development Program
Additional Pictures/Video
Caldwell Fire – PPE Report: Pants
Manufacturer: Topps Safety Apparel, Inc.
Standard: NFPA 1977, 2016 Edition
Date of Manufacture: April 2018
Fabric: 60% Kevlar, 40% Nomex IIIA
Condition:
The pants were laundered before inspection, so the extent of fuel staining was not determinable.
Dye sublimation1
Outside of pants:
▪ Present on both legs with the left leg having the most sublimation.
▪ The left leg sublimation of the fabric is approximately 35 square inches. Sublimation
to the fabric fuzz (loose fibers) extends up the back of the pants 32 inches from the
cuff and the front of the pants 28 inches from the cuff.2
▪ The right leg has no fabric sublimation. However, fabric fuzz on the right leg shows
sublimation from the cuff up the leg approximately 10 inches.
Inside of pants:
▪ Left leg fabric sublimation continues through to the inside of the fabric.
▪ Sublimation to the fabric fuzz on both right and left legs with the left extending up the
back of the pants 25 inches from the cuff and the right leg extending up 18 inches
from the cuff.
Charring
There was no charring of the fabric visible.
Front Back
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Inside Front Fuzz Dye Sublimation
1Dye sublimation (the yellow/orange color) occurs when heat bakes the dye from the
fabric. This occurs at 450 degrees Fahrenheit. 2Sublimation to fabric fuzz occurs more rapidly than sublimation to the entire thickness
of the fabric. Fabric fuzz sublimation usually indicates shorter duration exposure to high
temperatures while fabric sublimation indicates longer exposure.
Material and Characteristic Temperature (°F)
Fuel Flame 1600
Kevlar (Para-aramid) Cloth – char 970
Kevlar (Para-aramid) Cloth – dye sublimation 450
2ndHuman Skin – Degree Blister 130
Burn Injury
The firefighter received 2nd degree burns above the boot to the left leg.
Front of Left Leg
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Recommendations/Reminders:
Reminder:
Wildland firefighter clothing is not designed to protect the wearer against burning fuel on the
material, and the fabric will not extinguish the burning fuel. Wildland firefighter clothing
provides limited thermal protection, and the direct flame contact associated with burning fuel on
clothing will eventually conduct through the fabric to the skin underneath, resulting in burn
injuries.
Prevention:
In testing conducted by the National Technology and Development Program, wearing over-the-
calf wool blend socks has been shown to reduce burn injuries to legs when fuel is ignited on
pants.
Burning fuel on pants video.
Actions to burning fuel on pants:
“Stop, drop, and roll” does not readily extinguish burning fuel on Flame Resistant (FR) clothing.
Additionally, it appears that attempting to swat or pat out burning fuel can increase the fire
intensity. There are some actions that can be taken to extinguish burning fuel on FR clothing.
However, these actions require human performance in very stressful situations.
1. Unbuckle and remove pants down to ankles or below boots. This reduces flame lengths
and removes the heat from next to the skin, allowing the individual to extinguish the
flames away from the legs. This method is preferred for large areas of burning fuel on
pants.
2. Use an accessible water bottle to pour on the flames to extinguish the burning fuel.
3. Drop to knees and smother the flames with a gloved hand. This method is suitable for a
small area of burning fuel on the pants.
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Additional Photos and Videos:
Two views of the rear bumper of truck Truck-1: The photo above is the undamaged driver’s side. Note the area within the red circle: There is no gap between the black plastic bumper covering and the white tailgate. The photo to the right, is the passenger’s side of Truck-1 that was damaged by the burning fuel flowing out of the bed of the truck. Note the area in this red circle: The damage is clear in that the black plastic bumper cover has melted and no longer meets the white tailgate. Investigators believe the truck was parked with the passenger’s side slightly lower than the driver’s side, allowing the burning fuel to leak out of the seam where the tailgate meets the bed of the truck.
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Supplemental Videos:
Filling Torch The FLA Team looked at equipment like the jerry cans and drip torches used on the Caldwell Fire at the time of the injury. This video shows a Team member using a military-style jerry can to pour fuel into a drip torch.
Filling Torch: https://youtu.be/lkHuhCJkcXQ
Half Full Jerry Can Tipped Over This video demonstrates leakage from a tipped jerry can. The container in the video was half full, simulating cans that may have been used to fill up drip torches on the Caldwell Fire.
Half Full Jerry Can: https://youtu.be/_0hcGSB6IAM
Reenactment When Lava-1 got out of the truck and looked over the bed rail, he could see one container spitting fire and it seemed to be venting around the pull handle. This video is a reenactment of the actions taken by Lava-1 to remove the fuel from the truck and how he responded to the flame on his Nomex pants.
Reenactment: https://youtu.be/i9MQfh-F8e4