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Accident Report
Fatalities & Injury
July 17, 1976

Cover and Contents


I. Events Prior to Accident

  1. Location
  2. National Fire Situation
  3. Fire Environment
    1. Weather
    2. Topography
    3. Vegetation and Fuels
  4. Origin and Initial Suppression Effort

II. Fire Behavior and Burning Sequence on July 16 and 17, 1976

  1. General Situation
  2. Prior Weather
  3. Fire Behavior Appraisal
  4. Fire Behavior July 16
  5. Burning Sequence July 17
  6. Chaparral Model Nomograph
  7. Fire Behavior Summary

III. Suppression Effort and Accident Sequence

  1. Accident Sequence
  2. Post-Accident Rescue and Medical Action

IV. Investigation

V. Organization and Management

  1. Fire Overhead and Crew Assignments 7/16-7/17/76
  2. Overhead Qualification and Experience
  3. Crew Qualification and Experience
  4. Logistical Support
  5. Fire Planning and Intelligence
  6. Aviation Management Activity

VI. Findings

  1. Mechanical Factors
  2. Physical Factors
  3. Human Factors
    1. Crew
    2. Overhead
  4. Management Factors


Battlement Creek Fire 1976-2006: Thirty Years of Lessons Learned, Powerpoint presentation for the Colorado Fire Training Officers Association, .ppt file, 3.7 mb

No Fire Shelters in British Columbia, July 25, 2005 safety bulletin explaining their change in policy, .pdf file, 2.2 mb




Accident Report
Fatalities & Injury
July 17, 1976

VI. Findings

A. Mechanical Factors

There were no mechanical failures that contributed to the accident.

On-fire radio communication equipment was adequate.

Adequate air support and line workers were available.

The Mormon Lake Crew was wearing the latest Nomex fire resistant shirts.

Fire shelters were not used. They were not requested or supplied to the fire.

Fire shelters might have prevented the fatalities at the refuge site. Additional data to confirm this has been requested from Missoula Equipment Development Center.

Policy on issuing and carrying shelters has not been established for the BLM in Colorado.

B. Physical Factors

Fire behavior was not unusual and was reasonably predictable.

Fire was dominating the local winds at time of accident, not vice versa.

Fuel condition was unusual for this area because of a late spring freeze.

The Mormon Lake burnout squad and line building squad could not see fire buildup below them in the draw.

The fire buildup was observed by many people on the fire including the fire boss, line boss, adjacent sector boss, scout and aircraft crews. Its potential rate of spread was underestimated by them.

Topography did not prevent crew movement.

A steep draw on a southwest exposure and readily available fuels provided the conditions for rapid upslope fire movement.

C. Human Factors


The Mormon Lake crew was in good condition, well-disciplined, and morale was high. They were observed to be a highly productive crew the day before.

Crew was specifically selected by fire boss for this assignment because of apparent expertise and previous day's performance.

Crew boss and squad bosses were serving in those positions for the first year, but had worked together on 17 fires this year.

The crew boss, with the sector boss and line boss, had taken an aerial reconnaissance flight prior to beginning burnout.

During burnout, crew boss and squad boss were serving as working members of the four-man burnout squad. No lookout was posted by the squad.

The line-building portion of the crew was ordered to evacuate by the crew boss. He asked for and received confirmation that they had reached the preplanned safety area.

Burnout squad did try to go to the same preplanned safety area but the fire had crossed their planned route.

Burnout squad then attempted to reach their preselected safety area, but were blocked by the fire.

Better alternate escape routes over the ridge away from the fire were available.

Burnout squad remained together, communicated their situation to the sector boss, and took survival precautions at direction of crew boss with no evidence of panic.

The four-man burnout squad remained together when overrun by the fire.

Sometime during or immediately after the fire passed over them, two men of the burnout squad left their refuge site and ultimately perished.

The remaining two men of the burnout squad stayed in place. The survivor stated that he remained prone while the fire passed over.


New interagency fire suppression qualification standards have been established recently.

The new standards have been adopted nationally by the Forest Service and are being pilot tested by the BLM in Montana and New Mexico.

Standards applicable to this fire were the existing USDI standards, dated April 23, 1973.

Some members of the fire management team did not meet existing USDI standards.

Had the new interagency standards been applicable some team members would not have been qualified for the jobs to which they were assigned.

The following positions were not filled on this fire:

Tractor boss, fire behavior officer, equipment officer, communication officer, air attack boss, and others.

Sector boss and line boss relied heavily on Mormon Lake and Happy Jack crew boss judgment to complete the crews' assignments.

The fire boss issued a strong and direct order to get out of the area just prior to the fire's uphill run to an individual in an adjacent area. This order was interpreted by the adjacent sector boss who was observing the situation as being directed to the Mormon Lake crew's sector boss. Because of this he did not issue a warning to evacuate that he was about to give to the Mormon Lake crew's sector boss.

The crew boss was given specific instructions by the sector boss to move the line-building squad to the safety area.

The sector boss observed what he thought was the burnout squad moving out to the heliport, adjacent to the safety area. He issued no specific instructions to move the burnout squad to safety.

D. Management Factors

Fire team had not worked together previously and were not a pre-organized project fire team.

The interagency nature of the fire management team was not a problem.

The plans and service organization was assembled at fire camp approximately 24 hours prior to the accident.

There was an absence of key support positions in the plans and service function which resulted in members of team doing other duties which detracted from their primary assignment.

A central point of ordering and followup at the fire was not established.

Work assignments and instructions were verbally communicated to crew boss by fire boss, line boss, and sector boss.

Maps and written instructions were not used in briefings or distributed.

Mormon Lake crew did not get to line until approximately 1030 due to planned helicopter not arriving when anticipated.

Weather intelligence was not formally and regularly gathered on the fire. Spot forecasts were not made until Sunday.

Previous day's fire behavior should have alerted the fire organization as to the probable fire behavior and served as a background and clue to alternative escape routes, suppression action, etc.

There was no aerial reconnaissance by the fire team between 1100 and 1500, July 17, 1976.

There was no intelligence requested nor given from aircraft over the fire, although aircraft were present most of the time.

The July 17 burnout operations of Happy Jack and Mormon Lake crews were not tightly coordinated and controlled in the plans for the day or during execution by the line boss and fire boss.

Burnout at bottom of draw moved slowly at first but accelerated up the steep slope and cut off the Mormon Lake squad and then overran them.

Various overhead were aware of the position of the burnout squad's activity, but the individual crews were not aware of each others position or activity.

No formal lookout with communications was posted for the burnout squad.

Rescue effort was prompt and professional and effective.

This accident was not caused by any single factor, rather by several contributing factors. There is no evidence of individual misconduct.

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