e-346 roll-over learning review

E-346 Roll-Over

Vehicle Accident

July 12, 2015

Facilitated Learning Analysis

E-346 Roll-Over Learning Review 2015

U S D A F o r e s t S e r v i c e P a c i f i c S o u t h w e s t R e g i o n

The FLA team, while interviewing those who participated in

this incident, experienced many different perceptions of how

the events unfolded.

This can be attributed to the “fog of war”.

Because of this overlapping or missing information, there is a gap.

It is in this gap—created by the different perceptions—that the

learning takes place.

CONTENTS

A. THE INCIDENT………………………………… 4 B. FIRST ON SCENE………………………………. 7 C. AT THE HOSPITAL……………………………… 9 D. INCIDENT TIMELINE……………………………. 10 E. LESSONS LEARNED…………………………….. 11 F. ACKNOWLEDGEMENTS…………………………. 12 G. REVIEW TEAM………………………………… 12



IT HAPPENED IN AN INSTANT!

“The SUV seemed to

come out of nowhere.

It hit us and suddenly

the engine was sliding

sideways across the

road!”

THE CAPTAIN’S ACCOUNT “We had made it out of the city traffic, and were on the two-lane road. After 10 days I was familiar with the route of travel and I was able to relax some. Suddenly a vehicle appeared on my side of the engine, I yelled “Oh #@&!” The vehicle must have been tucked right in behind us. I had not seen anything in the mirror. I heard a crunching sound and the engine started sliding to the left. We were sliding … then we were in the air.

I must have blacked out because the next thing I remember was waking up not knowing

where I was … I went for the door… all I saw was dirt and glass. I undid my seatbelt and

yelled for the crew to get out. I could hear a gurgling sound as if it were water or possibly fuel

… and Derek screaming. The radio console was on me. I was able to pop the windshield out

and crawl out of the truck. I don’t remember much after that until I was in the ambulance.”

-Engine Captain



“I remember thinking … Why

was there a car passing us on

that side?”

~Firefighter

A. THE INCIDENT

Early in July 2015 the Sierra Nevada Mountains of California experienced widespread thunderstorms. The Sierra National Forest, located in the central Sierras, experienced a large number of fires from these storms and ordered additional resources, including several single increment engines, to help in the suppression effort.

Engine 346 was mobilized and assigned to the High Sierra District. After a few days, for span of control and leadership purposes, Fire Management organized the single increment engine resources into a Strike Team configuration.Because of the limited logistical support available within the Forest boundaries, the Strike Team would return to Clovis (just east of Fresno) each night for meals and lodging.

Sunday July 12th started out similar to the previous days for E-346. After spending the night in a motel, the crew ate breakfast and obtained lunches at a local store before starting the ½ hour drive to the local District Office where they would meet the Strike Team Leader for the morning briefing and daily assignments.

As E-346 travelled east on Hwy 168 they transitioned out of the urban area into the more

rural outskirts of Clovis. As they did, the road changed from four lanes into two. Continuing

east, the engine entered a sweeping left hand bend in the road. Near the end of the curve

was a Tee intersection with a clearly delineated right hand turn lane (see photo below).



As the engine traveled through the intersection, a previously unseen SUV suddenly tried to pass the engine on the right. Quickly running out of pavement, the SUV—now in the dirt shoulder—turned into the engine, hitting it in the right front wheel.

The violent impact, effectively working as a “reverse” Pit Maneuver1 put the ~30,000 lb. engine into a spin across the on-coming lane.

Sliding and spinning sideways across the oncoming lane, the engine exited the roadway and momentarily became airborne before landing in an open field.

After trying to pass E-346 (red line) on the right hand side, the SUV (blue line) turned into the engine—impacting it on the right side front wheel. This forced the engine into a left hand spin across the oncoming lane. The engine, now spun almost 180 degrees around, exited the roadway, and rolled

several times into the adjacent field. The SUV spun to the right and rolled as it exited the roadway.

1 The PIT maneuver, or “Pursuit Immobilization Technique”, is a tactic used by law enforcement by which a pursuing car can force a fleeing car to abruptly turn sideways, causing the driver to lose control and stop.



“I was sitting in the middle rear seat, leaning forward talking with

the Captain. He must of seen something in the mirror because he

suddenly yelled out ‘Oh @#$%!’

I looked over througth the right rear passenger window and saw

the top of a vehicle passing us. I thought to myself:‘Why is there a

vehicle there?’ It was passing us at pretty good clip. I followed it

in the front passenger window.”

Suddenly, the engine was sliding across the lanes. All I could see

was the field, we are going to roll… I put my arms up to brace

myself and then it was like being in a spaceship… I remember

pens and binders floating in front of me … I remember thinking:

‘How can we still be rolling?’”

Firefighter

Impacting the ground on the right side, the engine appears to have partially cart-wheeled then rolled several times, eventually coming to rest on its right side.

The crew of the engine, some unconscious, all disoriented and with various injuries, worked to extricate themselves and their injured partners from the heavily damaged cab.

Other engines in the Strike Team, which were 10 to 15 minutes behind E-346, came across the accident scene and quickly jumped into action to secure the scene and assist Local EMS and CALFIRE resources triage and package the injured firefighters.

“Skylife” was used to transport the most seriously injured. Ambulances took the remainder of the crew to two different local hospitals.

Medical evacuation took less than 30 minutes.

“Highway 168 is a race. That area is a chokepoint Drivers come out of an urban interstate

environment and expect to continue to travel at those speeds.

Drivers do unpredictable things.”

Longtime Local

Damage caused by lug nuts and tire of the engine to

driver’s door of SUV.



B. FIRST ON SCENE

The following narrative is a combined account of the U.S.

Forest Service engine crew members who arrived on scene.

As we first came across the

accident scene, we saw a law

enforcement vehicle with its

lights on as well as various other

POVs. We noticed the rolled SUV

on the right hand side of the

roadway and positioned our engine behind it. Looking across the road, we initially saw what

we thought was a piece of farm equipment in the field. It took a minute before we realized it

was actually a Forest Service engine on its side.

Soon we saw two crewmembers appear from around the front of the engine and walk

toward us.

I instructed the crew to PPE up and grab the medical equipment. I called Sierra Dispatch to

notify them of the accident. A

Sheriff Deputy and a person who

identified themselves as an off–

duty medic were on scene. The

medic said he had already activated

the EMS response including an air

ambulance.

We gave him some gloves and two

of the crew followed him to the

engine. The injured crewmembers

walked up to us and we quickly

assessed them. Soon another

injured crewmember walked over

to us. By that time another engine

from our strike team was on scene

and they were able to assist with

the patient assessments.

I Saw a Person Covered in Blood . . .

“As I came up on the accident scene, I first noticed the

rolled SUV on the right shoulder. I noticed a lot of dust

out in the field on the other side of the road and figured

it was just a farmer disking his field.

By the time I had pulled over, the dust had cleared and I

saw it was actually a forest engine on its side. I saw a

person covered in blood coming toward me waving. I

ran toward the engine and saw a person climbing out of

the passenger window (which was now the top).”

“I was worried about a fire in the dry grass and started

to look for a fire extinguisher. As I got to the front of the

truck I could hear screaming from inside, so I pulled the

windshield back.

There were three inside There was one guy just coming

to. I helped him out of the engine. The other guy was

trying to wake his buddy up so I went back in to help

get him out.”

~Good Samaritan

“We initially saw what we thought was a piece of farm equipment in the field. It took a minute before we realized it

was actually a Forest Service engine on its side.”



“I remember the

carnage, the

amount of debris

strewn across the

field, the injured

coming toward us.

It was like a scene

from the walking

dead!”

~ Emergency

Responder

“We arrived on

scene and

focused on the

SUV—until one of

the firefighters in

the back saw the

engine in the

field and said:

‘Oh! That’s one of ours!’”



“The Hospital Liaison from the Forest

and our contact at ASC were both outstanding!”

- Division Chief

C. AT THE HOSPITAL

Having a Hospital Liaison available to respond and engage in a timely fashion is critical.

This individual should be well versed in the administrative requirements of the Agency as well as being able to ask the “tough” questions to hospital staff and ensure proper care of the injured employee. The FLA Team learned the less seriously injured members of the crew were “extremely anxious about the status of the other crewmembers” that were in another hospital. Understandably, they wanted to see them as soon as possible.

As soon they were released, these crew members were taken to the hospital where the two seriously injured crewmembers were. Upon arrival, one of them exhibited delayed symptoms and had to be readmitted for treatment. Eventually, all crewmembers exhibited delayed response to the trauma they had experienced and were readmitted for follow-up care.

A normal response for a leader or crewmembers, even if they

themselves are injured, is to want to take care of their

coworkers.

A mass casualty event such as this, where an entire crew is

involved, creates many challenges.

The Hospital Liaison needs to be mindful of and assure the crew

that the others are being taken care of.

This could take the “burden of worry” off, so they can get

appropriate care.

FLA Team

“It’s just a bump. Move on!”

–Injured firefighter to

responder, wanting the more

seriously injured to be cared

for first.



D. INCIDENT TIMELINE

The total elapsed time, from initial report to the time all patients had been transported was 31 minutes.

0737 – “911” call is received at the CALFIRE Fresno-Kings Ranger Unit (FKU) dispatch center of a “traffic collision with ejection” on eastbound State Highway 168

0740 – FKU dispatches two CALFIRE engines, a Battalion Chief, along with local EMS.

0744 – While enroute to the incident, the CALFIRE Battalion Chief requests one additional engine to respond—based on the number of patients.

0746-0750 – Three other engines from the Strike Team arrive on scene.

0748 – Two CALFIRE Engine companies arrive on scene.

0750 – A “Skylife” Air ambulance is dispatched to the incident with a 5-minute flight time from Fresno/Yosemite International Airport.

0750 – An FKU Battalion Chief arrives on scene and assumes Incident Command.

0803 – The helicopter arrives on scene and lands in the field near the engine. One seriously injured patient is loaded onboard and taken to County Regional Medical Center.

0805 – CALFIRE contacts Sierra National Forest and advises that there were two vehicles involved and that the engine rolled three times.

0807 – The Incident Commander reports that two seriously injured patients will go to County Regional Medical Center and the remainder will go to Saint Agnes Hospital.

0808 – The Incident Commander reports “all patients have been transported.”

0816 – The Incident Commander radios to his dispatch center that “we may need to extend CISM (Critical Incident Stress Management) to the personnel.”

0820 – FKU activates CISM for the responders.

0843 – SNF Battalion Chief will be contact for CISM.

0852 – SNF Law Enforcement Officer on scene collects personal gear from Engine 346.

0929 – Strike Team Leader enroute to hospital with personal effects from Engine 346.



“WOW! That is pretty wild. I had been curious about what had

happened because I had been knocked out. Thanks for coming and

answering my questions, I don’t know what happened.”

~Injured Firefighter to visiting rescuers

“I am proud of our Agency for the amount of support

for myself and my family.”

~Injured Firefighter

E. LESSONS LEARNED

Seatbelts work!

Vehicle occupants involved in accidents have been injured by loose objects in the cab which had become projectiles. Securing objects such as hand-held radios, water bottles, hard hats and line gear is important to prevent injuries.

The center radio console coming loose is a concern to Regional Fleet Management. They will specify a more secure method of mounting radio consoles.

Timely peer support was extremely effective for the responders and those involved in the incident.

Forests should have an accident/hospitalization plan which addresses: o Training for those functioning in the roles of Patient Advocates/Hospital

Liaisons, both administratively and how to interact with hospital staff. o Accounting for timely notification and mobilization after hours. o Incidents with multiple casualties which may require both a Hospital

Liaison and a Family Liaison.

Providing opportunity for first responders to visit patients in hospital provides closure to all involved.

Early direction by leadership of “no blogs, no posts, no social media” by first responders helped with rumor control.

Gathering personal effects (especially cell phones and wallets) and returning them to injured parties as soon as practical was greatly appreciated.



F. ACKNOWLEDGEMENTS

The Review Team would like to thank the Forest Supervisors and staff of the Sierra

and Stanislaus National Forests as well as the personnel involved in the incident for

supporting the FLA process.

They would also like to thank the Crew of E-346, who took the time to tell their

amazing story to the Team. We hope you are all quickly healed!

G. REVIEW TEAM

Kevin Elliott

Forest Supervisor,

Sequoia National Forest

Tom Plymale

Division Chief,

Los Padres National Forest

Mike Heckendorn

Fleet Manager,

USFS Pacific Southwest Region

Dave White

Fleet & Equipment Specialist,


Jonathon Merager

Prevention Tech,

Angeles National Forest

Jason Ownbey

Fleet Mechanic Inspector,

Six Rivers National Forest

Pete Duncan

Fire Operation Risk Manager,


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