Cover & Table of Contents
Investigation Process Summary
Causal Factors and Contributing Factors
Appendix 1 — Fire
Behavior Analysis Summary
Appendix 2 — Fire Operations Analysis Summary
Appendix 3 — LCES Analysis Summary
Appendix 4 — Standards for Fire Operations Analysis Summary
Appendix 5 — Compliance Analysis Summary
Appendix 6 — Fire Weather Analysis Summary
Appendix 7 — Human
Factors Analysis Checklist Summary
Appendix 8 — Personal Protective Equipment Analysis Summary
Appendix 9 — Equipment Engine 57 Analysis Summary
Appendix 10 — Video Documentation Listing
Appendix 11 — Glossary and Acronyms
Riverside County, California
October 26, 2006
Causal and Contributing
The human elements are critical factors in the evaluation of this investigation.
A risky decision or a series of risky decisions appear to have contributed
to this dangerous situation from which there was no room for error.
Causal Factors are any behavior, omission, or deficiency that if corrected,
eliminated, or avoided probably would have prevented the fatality.
Causal Factor 1.
There was a loss of situational awareness concerning
the dangers associated with potential fire behavior and fire environment
while in a complex wildland urban interface situation.
(Findings #12, #16,
#18, #19, #20, #21, #22, #23, #25, #26, #32,
Causal Factor 2.
The decision by command officers and engine supervisors to attempt
structure protection at the head of a rapidly developing fire either
underestimated, accepted, and/or misjudged the risk to firefighter
(Findings #9, #10, #11,
#16, #17, #18, #19, #20, #22, #24, and #26)
Contributing Factors are any behavior, omission, or deficiency that
sets the stage for an accident, or increases the severity of injuries.
Contributing Factor 1.
Organizational culture - The public (social and political) and firefighting
communities expect and tolerate firefighters accepting a notably higher
risk for structure protection on wildland fires, than when other resources/values
are threatened by wildfire.
(Findings #8 and #9)
Contributing Factor 2.
Fire environment - Santa Ana winds came into
alignment with the “unnamed
creek drainage” and the inversion was penetrated by the thermal
uplifting from a fire run which contributed to extreme fire behavior
and area ignition.
(Findings #15, #19, #20, and #21)
Contributing Factor 3.
Fire environment - The fire burned in rugged terrain and the burnover
occurred in the upper end of a steep drainage with fuel loads at seasonal
low fuel moisture levels.
(Findings #18, #22, and #23)
Contributing Factor 4.
Fire environment – The terrain and road
system limited access to Type III or smaller fire engines.
#14 and #24)
Contributing Factor 5.
Span of control – The five Forest Service
fire engines and March Air Force Base 10 fire engine were not supervised
by a strike team/task force leader. This contributed to increased
complexity and span of control.
(Findings #8, and #12)
Contributing Factor 6.
Communications – The
five Forest Service engines used a Forest Service tactical radio
frequency not assigned to the fire for tactical discussions. Effective
communication controls were not in effect prior to the incident.
(Findings #32, #33,
Contributing Factor 7.
Leader’s intent – Communications
between Branch II and Engine 57 Captain at the Octagon House were
not clear or understood.
Contributing Factor 8.
A contingency map developed in 2002 for the area that identified
structure location/defensibility and Mountain Area Safety Taskforce
Interface Protection Plan information was not used for strategic or
tactical risk assessments or plans.
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