Meadow Creek Fire Accident Prevention Analysis
CRRRAAACK! The unmistakable sound of a tree‘s holding wood popping ricocheted off the steep canyon walls early that July 5th afternoon. Shannon instantly recognized the sound. She knew a tree was falling, but where? She was standing on a log jam above Main Elk on the White River National Forest looking at her hand-held GPS. As she looked up in the direction of the sound, she made a split second decision that saved her life; Shannon launched off the log. Branches of the 60 foot tall, 12-inch Douglas fir caught her in mid-air, twirled her around, and slammed her onto the rocky streambed 5 feet below.
The seriousness of her injuries was not fully understood by Shannon or her supervisor for nearly 2 weeks after the accident. Word of this accident did not reach fire managers on the White River National Forest for almost a month. On August 3, 2010, the Deputy Regional Forester for the Rocky Mountain Region commissioned an Accident Prevention Analysis team to review the circumstances surrounding the accident and the delays in reporting. An Accident Prevention Analysis (APA) is conducted under the principles that reinforce the model of ―Just Culture.‖ The instructions to the team were to identify opportunities to strengthen our safety culture without fear of reprisal and with the learning vital to accomplishing our mission safely and successfully.
The team interviewed individuals involved with the Meadow Creek Fire on the Rifle Ranger District of the White River National Forest and employees at the home unit of the injured firefighter on the Ashley National Forest. Interview questions covered the fire, the accident, follow-up, and eventual reporting of the accident. The story that follows is based on those interviews. Participants were also asked what lessons they think firefighters and managers could learn from this incident. Thus, in addition to the story, the report also lists those lessons learned by firefighters and managers. Finally, the APA team conducted an analysis of the lessons learned and the report provides insights into organizational and cultural conditions that contributed or enabled the accident or the delays in reporting. Also included are appendices that contain a chronology of events, a visual depiction of the messages that people heard, and a set of discussion points to define terms and to elaborate upon points made in the APA team analysis lessons learned.
Even though this incident was specific to two wildland fire modules, the lessons learned apply to all resource types who might find themselves in a similar situation, such as hotshot crews, smokejumpers, helitack and engine crews. The APA Team‘s Lessons Learned Analysis identified the following conditions that may have contributed to or enabled the accident and delays in reporting: The APA Team found the modules were implementing what they thought was leader‘s intent, but without the leaders‘ full understanding of the hazards and risks being accepted on their behalf. A general lack of understanding of reporting an accident as an opportunity for organizational learning about risk management caused a delay in reporting, and even led to allegations of a cover-up. Certain human factors affected individual and collective sensemaking about the accident and the injuries, and contributed to delays in accurate information being widely shared in Meadow Creek Fire Accident Prevention Analysis Page 6 a timely manner. Human factors can also help to explain strong reactions to news of the tree strike and the resulting injuries once this information became more widely known. Based on the lessons learned analysis, the APA team developed and presented recommendations to Region 2 for further consideration and action. This report will be posted on the Wildfire Lessons Learned website for organizational learning.