USFS Releases Florence Fire Tree Strike Fatality Analysis

SEELEY LAKE – The U.S. Forest Service released the Facilitated Learning Analysis for 19-year-old firefighter Trenton Johnson who lost his life when hit by a falling snag on the Florence Fire near Seeley Lake July 19, 2017. Johnson was a first-year firefighter with the 10-person module from the Missoula-based Grayback Forestry, Inc.'s 20-person Type 2 Initial Attack crew.

The report spells out in detail the events leading up to and following the accident. Based on training records provided from all agencies involved, the personnel dispatched to the Florence Fire were qualified in the positions in which they were functioning. The Florence Fire was also managed according to normal standards.

The FLA team interviewed all of those involved in the incident that were available. They shared lessons learned. Along with the FLA team, they came up with recommendations based on the lessons learned to be used to review the tragedy.

The Story

Following a lightning storm, Mount Morrell Lookout called in a smoke July 18. The Seeley Lake Ranger District Fire Management leadership sent a Type 5 Incident Commander (ICT5) with four first-year firefighters to the reported smoke by Florence Lake the next morning.

"With many of the District's seasoned firefighters off duty, this was a good opportunity for the first-year firefighters to gain some experience on initial attack and they were excited," read the report.

The five-person crew arrived at the fire around 11 a.m. July 19. It was around 0.5 acre burning in thick subalpine fir, lodgepole pine and snags with a lot of downed trees on the ground. It appeared to be started by a lightning strike.

The ICT5 recognized that the fire environment complexity was extremely high due to the number of snags. The ICT5 ordered more sawyers and resources due to the complexity. The firefighters engaged the fire but pulled back to the meadow nearby because the fire was hot and there were a lot of snags, one which they watched fall into the fire.

At 12:30 p.m., the ICT5 requested bucket drops. Feeling that the fire's complexity level had exceeded the ICT5's qualifications, the ICT5 also requested a Type 4 Incident Commander (ICT4). A separate four-person helitack crew arrived and helped with snag mitigation.

The ICT4 assumed command of the fire at 2:11 p.m. bringing three additional firefighters from the District. The ICT4 confirmed additional resources were needed. Firefighters were continually reminded of the snag hazard and to keep their heads up. After group tree torching was observed following a sawyer felling a snag into the fire, the helicopter returned for a second round of bucket drops. The bucket drops were effective and allowed firefighters to work closer to the fire's edge.

The 10-person module arrived on the fire just after 4:30 p.m. They had being reassigned from the Sapphire Complex. This was their first initial attack of the season and for some, their first initial attack ever.

As they hiked in, they were "hyperaware" of all the snags, passing messages up and down the line to remind them to keep their heads up. They received their assignment to help the local crew secure the line. The ICT4 emphasized that there were a lot of snags in the area.

The module lined up behind the sawyers. A crack split the air and the Squad Boss looked up. The top of a nearby smoking snag lurched. "Snag!"

The firefighters "fell like bowling pins," some falling back and some to the side, while others dove behind trees. The top third of the 70 foot snag "whizzed by like a fastball," brushing against one firefighter's shoulder as it hit the back of another firefighter's helmet, knocking him to the ground and pinning his legs.

The local crew's EMT yelled to a firefighter to grab the EMT fire pack and sprinted to Johnson who was unconscious under the tree. The module's EMT began a head to toe assessment. The best sawyer cut the tree off of him and rolled Johnson with spinal precaution onto his back and continued their assessment.

Johnson quickly returned to consciousness and his vitals showed rapid pulse and respiration. He was alert and speaking. He knew his name, where he was and the year. The ICT4 reported to Missoula Dispatch at 5:03 p.m. that a firefighter was hit by a snag. A helicopter was requested to get Johnson off the hill as well as a ground ambulance for backup.

The helicopter, previously doing bucket work, returned to the incident. Seeley Lake Fire Department responded to the Seeley Lake Airport for a firefighter stuck by a tree with unknown injuries. Life Flight was ordered estimating arrival time in about 30 minutes.

The ICT4 accepted the closest helicopter, the one that had done the bucket work. Despite work to make the crews' safety zone a landing pad, the helicopter refused to land due to increased fire activities and snags leaning into the landing zone. They elected to land at a nearby helispot a couple hundred yards away. Life Flight landed at the Seeley Lake Airport.

The EMTs were unable to find any indication of broken ribs or spinal injury. Johnson struggled to breathe but said he was not in pain. The ICT4 informed dispatch that the injured firefighter is a code red with possible chest injury and needs to be extracted as soon as possible.

In 15 minutes, firefighters returned from the 0.25 mile run back to the engine with the trauma kit and Sked. The local EMT started a non-rebreather with oxygen, worked with the module's EMT to apply a cervical collar and rolled Johnson, taking spinal precautions, onto the Sked.

The local crew and module worked to carry Johnson to the helicopter. Several firefighters led the way, clearing a path for the others carrying the Sked behind them. The firefighters took turns carrying the Sked, ensuring that nobody got too tired and they could move as quickly as possible.

They arrived at the helicopter about 15 minutes after leaving the accident scene. The helicopter's back doors had been removed for the season and the Helicopter Manager decided that it wasn't safe for the EMTs to accompany the patient in the helicopter since there were no seat belts available. One helicopter crewmember rode in the back facing and talking to Johnson during the three-minute flight to the airport.

Before take off, Johnson was alert, talking and knew his name. Radial pulse was dropping and respiration was difficult and slow. By 5:43 p.m., 40 minutes after the tree strike, the helicopter was en route to Seeley Lake Airport.

"I would have left the helicopter spooled up if I had known it was that bad," said the Helicopter Manager as quoted in the report.

The Seeley Lake Rural Fire Department and Life Flight were waiting at the airport when the helicopter approached for landing at 5:46 p.m. They were unaware of the nature of the firefighter's injury.

Medics off-board Johnson who was unresponsive and without a pulse. They began high performance CPR, inserted breathing tubes and loaded Johnson into Life Flight. Life Flight left for St. Patrick's Hospital at 6:08 p.m.

The crews were pulled off the fire. The firefighters were optimistic – the extraction had been quick and Johnson had been talking as the helicopter left. When the firefighters arrived at the District Office, they were devastated to hear that Johnson had succumbed to his injuries.

Administrative leave was granted to the local crew members and the module took a few days of down time. Several Critical Incident Stress Management sessions were held. The FLA team interviewed as many key participants as were available.

Suggestions Recommended

Although the Florence Fire was managed according to normal standards, those involved in the incident identified lessons learned to inform future trainings and incident responses. From these lessons learned during the review process, the non-exhaustive list of recommendations suggested by interviewees and FLA Team members included:

• ICs should be assigned to initial attack fires based on the complexity of the fire environment rather than on management type. Management types should be categorized as Initial Attack, Extended Attack or Large Fire management rather than the current 1-5 system.

• A tactical tool should be developed that can quickly assess the complexity and risk of an initial attack fire and be used to determine the IC Type best suited for that particular fire.

• Leaders and operators should consider a tactical pause before engaging: "Stop, Think, Talk...then Act."

• Plan, practice and brief on protocols for an Incident within an Incident, including the 9-Line medical protocol.

• Under the leadership of an EMT, educate all crew members about medical equipment names, uses and location in the first-aid kit.

• Work with cooperators to improve medical responses to include mutually beneficial training exercises, equipment capabilities and interagency communications.

• Stage trauma kits and other medical supplies where they can be easily accessed.

• Rotate personnel carrying the Sked to maximize strength and endurance during transport as was done during this incident.

• Order Life Flight to the incident and allow the pilot to decide where and when to land. Life Flight may be able to off-board medical personnel at the incident to provide advanced medical care.

• National Crew Contracts' minimum medical equipment requirements, currently a 10-person first aid kit, should be upgraded to meet the needs of more severe trauma.

• Consider post-incident logistics. Forest/District leadership, together with dispatch, coordinated transportation for all affected crews, not only back to the Administrative Unit but to the Module's home base and to the employees' homes.

• Review Basic Firefighter Training (S-130) and Introduction to Wildland Fire Behavior (S-190) for content and presentation style to include field work and hands-on training to mirror Guard Schools, academies and apprenticeship programs.

• Provide additional training oversight, including on-site monitoring for quality and content, of contract equipment and crew vendors.

• Ensure minimum staffing for initial attack fires has appropriate personnel to allow for delegation of tasks and the experience levels that can assist in the management of the fire.

• Include direction in the Forest Fire Suppression Plan to utilize heavy equipment for initial attack where feasible, especially when there is significant personnel exposure to potential tree strikes.

For the full report visit https://mailchi.mp/f488b8b133d7/florence-fire-tree-strike-fatality-fla