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Esperanza Fire


Accident Review Board Action Plan


CDF Green Sheet


Accident Investigation
Factual Report

Cover & Table of Contents
Executive Summary
Narrative
Maps
Photographs
Timeline
Investigation Process Summary
Human Findings
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

US Forest Service shield Forest
Service
Washington
Office
14th & Independence SW
Washington, DC 20090

File Code: 6730.1
Route To:
Date: May 25, 2007 June 4, 2007
Subject: Accident Review Board Action Plan, Multiple Fatalities, Esperanza Incident, Region 5
To: Regional Foresters, R-4, Regional Forester R-5, Director, WO FAM, Director, WO OSOH

This letter supersedes my May 25, 2007 letter. A Chief's Office Accident Review Board (ARB) was convened on April 3-4, 2007, involving multiple fatalities of wildland firefighters.

A Forest Service and CalFire Accident Investigation Team conducted the investigation and presented the Factual Report and Management and Evaluation Report to the ARB. These reports were reviewed and approved after some revision. A series of actions were An action plan was developed by the ARB to focus on key items that, when implemented, could best prevent similar mishaps in the future.

Noting that CalFire has already approved this plan, I add my approval to the Board's recommended Forest Service/CalFire Action Plan. Please review the enclosed Action Plan and take the appropriate steps to ensure completion of each respective action by the assigned date. The Office of Safety and Occupational Health should be notified when the actions are completed.

The Board notes that some of these recommendations will require involvement and action by our partners. Therefore, the Board has recommended completion dates designed to provide time for proper response and implementation.

Questions about this enclosure should be forwarded to the Deputy Chief for Business Operations, Hank Kashdan, who served as the Board chair.

/s/ Abigail R. Kimbell
ABIGAIL R. KIMBELL
Chief

Enclosure

cc : Hank Kashdan
Allison Good
Ken McLean
Joe Walsh
Gary W Helmer
Cecilia Black

It's Cool to Be Safe


US Forest Service
ACCIDENT REVIEW BOARD ACTION PLAN
Esperanza Incident
April 3-4, 2007

FOR OFFICIAL USE ONLY

Recommendation 01A — Update the California Cooperative File Protection Agreement (CFPA) to include distribution of existing strategic high-risk interface geography location maps to compliment complement existing Direct Protection Area (DPA) maps.

RESPONSIBLE UNIT: USFS FAM Region 4, USFS FAM Region 5 (Coordinate with Cal Fire)
LEAD UNIT: USFS FAM Region 5
COMPLETION DATE: July 31, 2007

Recommendation 01B — Develop strategy to identify and map high risk interface locations in areas covered by the CFPA to complement existing DPA maps (i.e., highlight areas such as the Twin Pines basin area ).

RESPONSIBLE UNIT: USFS FAM Region 4, USFS FAM Region 5 (Coordinate with Cal Fire)
LEAD UNIT: USFS FAM Region 5
COMPLETION DATE: December 31, 2007

Recommendation 02 — Integrate California Forest Service fire management plans with the Riverside County Mountain Area Safety Taskforce (MAST) pre-fire and emergency plan (September 2004). Fire management plans should continue to be jointly developed and monitored to support the successful implementation of the Riverside County Mountain Area Safety Taskforce (MAST), Santa Rosa and San Jacinto Mountains Community, and the Wildfire Protection Plan (CWPP) – Draft Final (March 2006). Integrate action plans into departmental operating and prevention plans which need to be developed, prioritized, and implemented to aggressively move forward measures to improve fire fighter safety in a timely and effective manner. Continue follow up on the documented “lessons learned” resulting the from MAST interface zone training exercise held June 15, 2005 with an emphasis on safety items identified in the areas of command and control. Develop meaningful metrics and include those methods for agencies to measure and report to agency heads (CalFire and FS R5 Regional Forester) success of planning efforts.

RESPONSIBLE UNIT: USFS FAM Region 5 (Coordinate with Cal Fire)
LEAD UNIT: USFS FAM Region 5
COMPLETION DATE: March 31, 2008

Recommendation 03A — Update Serious Accident Investigation Training to include clarification about reporting requirements, collateral investigations, protocol information about Critical Incident Stress Debriefing (CISD), union involvement, report writing, and procedures for documenting near-miss incidents.

RESPONSIBLE UNIT: USFS WO OSOH
COMPLETION DATE: March 31, 2008

Recommendation 03B — Develop and integrate into each agency's Serious Accident Investigation processes/procedures the investigatory lessons learned from Esperanza.

RESPONSIBLE UNIT: USFS WO OSOH (Coordinate with Cal Fire)
LEAD UNIT: USFS WO OSOH
COMPLETION DATE: March 31, 2008

Recommendation 04 — Initiate a policy review of wildfire suppression risk management principles to enhance agency-wide performance and determine key factors to make educated risk decisions when operational assets are committed, or proposed to be committed in the wildland urban interface.

RESPONSIBLE UNIT: USFS WO FAM (Coordinate with Cal Fire)
LEAD UNIT: USFS WO FAM
COMPLETION DATE: July 31, 2007

Recommendation 05 — Based upon the outcome of recommendation #4, petition NWCG (National Wildland Fire Coordinating Group) to review the current S-215 Fire Operations in the Wildland Urban Interface, (I-Zone = interface zone same as wildland urban interface)

RESPONSIBLE UNIT: USFS WO FAM (Coordinate with Cal Fire)
LEAD UNIT: USFS WO FAM
COMPLETION DATE: September 30, 2007

Recommendation 06 — Promote the use of the Esperanza Fire Fatality Serious Accident Investigation Report as a learning tool to deliver a variety of strong messages to the fire community to emphasize the importance of risk management and the priority of life over structure protection. Communication methods shall address human factors and shall include: classroom case study (Fire Fighter Survival Case Study); personal testimony of involved fire fighters, staff rides, and other multi-media interactive technology to include in annual fire fighter refresher courses.

RESPONSIBLE UNIT: USFS WO FAM (Coordinate with Cal Fire)
LEAD UNIT: USFS WO FAM
COMPLETION DATE: March 31, 2008

Recommendation 07 — Update the similar terrain situational awareness poster to include a photo of the "unnamed creek drainage" from the Esperanza Fire.

RESPONSIBLE UNIT: USFS WO FAM
COMPLETION DATE: July 31, 2007

/s/ Hank Kashdan

HANK KASHDAN
Chair, Chief's Office Board of Review Accident Review Board

APPROVED_______X_________ DISAPPROVED w/remarks___________________
DATE_5/25/07_06/04/2007_____

/s/ Abigail R. Abigal Kimbell
Gail Abigail Kimbell
Chief

 


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