A 115-page report that explored the missteps that led to the death of a young firefighter can be boiled down to one damning conclusion: The fatal injury to Andrew "Andy" Palmer could have been prevented had his understaffed crew not opted to cut down a tree that it clearly was not qualified to cut down.
In the months ahead that hard, painful lesson will circulate among fire bosses and fire teams throughout the U.S. Forest Service and the National Park Service as managers work to ensure their firefighting teams have the information, knowledge, equipment, and supervision that was lacking on a smoldering northern California mountainside in July 2008 where that 18-year-old firefighter was mortally injured when a Ponderosa pine was felled and caused another pine to fall and hit him.
"It was a freak accident," said Whiskeytown National Recreation Area Superintendent Jim Milestone, who was the National Park Service liaison on the interagency team that investigated Andy Palmer's death. "They weren’t doing something that was totally wrong other than that the tree they were cutting was wider, it was a 36-inch tree, and they shouldn’t have cut anything bigger than 24 inches. ... It was a big tree. They shouldn’t have cut it down.
"But that tree, they felled it successfully, but then it hit that other one," continued the superintendent. "That other one came down. That’s where it gets into the complexity of falling, and that’s where a professional faller may have had the insight to recognize the danger of it. Furthermore, they weren’t standing where they were supposed to be standing. Andy was too close.”
While federal Occupational Safety and Health Administration requirements call for observers to stand off a distance equal to twice the height of the tree being cut -- in this case, 250 feet away -- the young firefighter was just 35 feet away, according to the investigation.
Lessons learned on-the-job can be tough to shoulder, particularly when they involve a death. Under the investigative approach the Forest Service takes into accidents, the Accident Investigation: Factual Report, Dutch Creek Incident, as the probe was named, was not undertaken to assess blame. Rather, it sought to accurately chronicle the factors that contributed to Andy Palmer's death and identify weaknesses in established protocols that could be addressed to prevent accidents down the road.
And yet, while the report pointed out numerous flaws and shortcomings -- a breakdown in supervision, lack of qualifications among crew members, ill-timed disagreements over both his treatment and transport to a medical facility -- none of the eight recommendations approved by acting National Park Service Director Dan Wenk and U.S. Forest Service Chief Thomas Tidwell this past July called specifically for more extensive training for firefighters or chain-of-command improvements.
And while "excessive motivation" on the part of Mr. Palmer's captain, the entire crew, the Olympic National Park fire officer, and the Operations Branch Director on the Eagle Fire in trying to get Mr. Palmer's four-man "engine module" team on the fire lines as quickly as possible was cited in the report as a contributing factor to the accident, none of the recommendations touched on ways to ensure safety practices aren't clouded by such motivation or the adrenalin rush that comes with fighting forest fires. Instead they spoke to developing a risk assessment for coping with "incidents within an incident," of better coordination with local emergency management services, of improving management of emergency evacuations from fire lines, and even of stocking two 8" by 10" sterile gauze pads in First-Aid kits.
Supervision, said Superintendent Milestone, is supposed to be inherent in the structure of fire camps, which can be imposing because of the intricate logistics.
“On the project fires that I’ve been involved with, you start out the morning going over the IAP, the incident action plan, and there’s safety briefings there. It’s attended by all the supervisors, and then the supervisors go back and disseminate that information to their crews. It’s a top-down incident command system, chain of command," he explained. "You have to pass the information on to your subordinates who are working on these assignments and the fire.
"... There’s a lot of people there, and there are a lot of moving parts in a fire, as they say, a big fire operation. I’ve been on fires where my supervisor has been watching very closely our crew and our crew activities and nothing got by him. And I’m sure that if that engine module had been kept together as an engine module there wouldn’t have been any problems," said Superintendent Milestone. “In this instance, they cut down a tree bigger than they should have and there was no supervisor right there.”
Managers at the National Interagency Fire Center, which provides overhead support for firefighting on public lands, will continue in the months ahead to dissect the pitfalls the investigation exposed. Among the troubling questions that linger are:
* Why was one of Andy Palmer's crewmates, in the process of removing hazardous trees for mop-up operations, cutting down a tree he was not certified to take down?
* Why was the crew dispatched to the field short its captain, who was the most-experienced and most-qualified sawyer on the team, and without a "qualified felling boss"?
* Why did the Division B Supervisor assume, and log down, that the two other members of Palmer's team were Class C sawyers, when the Operations Branch Director had "verbally confirmed with FC1 and FC2 that they were only B sawyers and stated 'no falling the trees over 24 inches.'"?
* Why did responding paramedics get into a dispute over how best to manage Andy's condition?
* Why was there confusion over summoning an appropriate medivac helicopter, and did that unnecessarily delay Andy's rescue off a burning mountain?
* Why did the two crew members who witnessed Andy's injury refuse to be interviewed?
That last question is among the most troubling. To this day only those two crew members, neither of whom was qualified to down a tree larger than 24 inches in diameter, know who felled a 125-foot Ponderosa pine that was 36.7 inches wide at the cut. Once felled that pine caused an uphill-leaning, four-and-a-half-foot-thick, 120-foot tall sugar pine to topple upslope. An 8-foot section of that tree hit Andy Palmer, shattering his left femur, tearing his femoral artery, and breaking a shoulder.
Though a hospital was just 11 miles away, nearly three hours passed before the young firefighter was hoisted into a hovering helicopter. During that time period, according to the investigation, there was time-eating, on-the-ground confusion among the responders as well as confusion between the Forest Service's safety officer, the Trinity County, California, sheriff's office, and a U.S. Coast Guard helicopter.
While the assistant U.S. Attorney in California declined to press charges in connection with the accident, whether the two crew members were reprimanded in any way is unknown due to Privacy Act considerations, said Roberta D'Amico, a National Park Service communications specialist with NIFC.
"The ramifications, personally these folks will never be the same," Ms. D'Amico said during an interview from her Boise, Idaho, office. "It’s a challenging situation because they’ve opted not to speak. But not knowing all the situations as to why they’ve opted not to speak, and I can’t of course speak for them, so I think that’s something the fire community is going to take a step back and evaluate how to improve that in the future, because they probably have a voice in this, and what can we learn from them? The whole process of the investigation, it’s not a personnel issue, it’s a lessons learned issue.”
Superintendent Milestone said the two fallers on the scene with firefighter Palmer could have their tree-falling certificates dropped a level or even taken away.
“That’s up to the supervisor to do disciplinary action. If someone on my crew went out and knowingly did something without proper supervision, they should be disciplined for it," he said. "There are options there. They can lose their faller’s credentials, their ranking. They can be demoted down to a lesser faller. A 'C' can go down to a 'B', a 'B' can go down to an 'A'."
While the death of Andy Palmer has certainly caught the attention of the firefighting community, Superintendent Milestone believes the specifics of the accident are not representative of what normally goes on on the fire lines.
"I think that the firefighters that are out there on the fire lines do an outstanding job. They’re well-trained. There’s a lot of years of experience with these crews," he said. "You can’t keep these crews year-round, the government can’t do that, no one can. Even the private contract crews are laid off in the winter time. This is an opportunity, it’s a young man’s, mostly a young man’s job. It’s tough work. These guys are out there. You need that youth and enthusiasm to go out there to be able to work the way that they do.
“That being said, I believe our firefighters in the National Park Service are well-trained and they come out to the fire line with a lot of experience and knowledge that not only has been gained individually but also trained to them through the experiences that they have, that they’ve been taught from other fires and other situations that people have gone through."
As more people review the report, said Ms. D'Amico, it's very possible more questions and more answers will surface.
“Now that the field has started to see it, people do want to know what else should we address in our annual safety refresher," she said. "Are there pieces that we should address? Technically, Andy, the qualifications that he had, the basic firefighter, and the basic sawyer, he was qualified in that position. ... The engine boss is qualified as a 'Faller C,' that was an individual with the higher qualifications. Then you had firefighter 2, who was 'Faller B,' then there was an engine boss trainee who was a 'Faller B,' and the Andy was a firefighter. He was with them, the more qualified people. Was he qualified as a firefighter, yes. Do they go out with people who are more experienced, yes. That's who he was with. Then you have the cascading effects of the rest of the circumstances."
More than likely, the spokeswoman said, there also will be more emphasis on managing the state-of-mind firefighters take onto the lines.
"There is an amazing level of change in the training arena to look at what are the emotional and human factors involved in firefighting that perhaps causes some of the accidents and incidents that we have, because there’s a certain repetition in the accidents and fatalities that we’ve had, unfortunately," she said. "So how do we improve the training with human factors? The 'Highly Reliable Organization' talks about 'overly simplify' things, don’t become complacent, and constantly drilling that in. I think more and more you see that in the annual refresher.”
From his vantage point, Superintendent Milestone predicts that the lessons from the Dutch Creek incident will benefit firefighting forces and, hopefully, improve their safety records.
“Firefighters are going to learn from the Andy Palmer incident at Dutch Creek to benefit future firefighters," he said. "The message, the word is getting out on it, and this report will have big implications I think. Lessons will be learned. I hope that it will strengthen the emphasis of people not doing things that they are not qualified for. That’s the message that I’m telling my firefighters. Only do what you’re supposed to do.”