Engine Boss Apprenticeship

Kates Basin Fatality Report

• Cover and Contents
• Executive Summary
• Incident Overview
• Investigation Process
• Findings and Recommendations
• Appendix 1 - Map of the Immediate Scene
• Appendix 2 - Sketch Map of the Entrapment Area
• Appendix 3 - Fire Behavior Analysis
• Appendix 4 - Oklahoma Engine #2 Findings
• Appendix 5 - Fire Orders and 18 Situations
• Appendix 6 - Operations & Critical Decision Gates/LCES
• Appendix 7 - Delegation of Authority

“How to Operate a Fire Apparatus Mechanic” — by Lt. Bill Dyer

KATES BASIN FATALITY REPORT

August 11, 2000

U.S. Department of Interior Bureau of Indian Affairs Wind River Agency Fort Washakie, Wyoming

APPENDIX 5 - FIRE ORDERS AND 18 SITUATIONS THAT SHOUT WATCHOUT

FIRE ORDERS     
Nine (9) Were Compromised

*1. Fight fire aggressively, but provide for safety first.

• PPE used

• Fought fire aggressively

• Engine #2 escape route was compromised.

*2. Initiate all actions based on current and predicted fire behavior.

• Positioning the Engine #2 in front of the fire, with unburned fuels between it and the fire, placed it at risk.

• Prior to the accident, the calculated rate of spread was 135 chains per hour. At the time of the entrapment, the calculated rate of spread was 879 chains per hour, with flame lengths of 30 feet. The timing of the tactical actions did not take into account the predicted weather and fire behavior.

*3. Recognize current weather condition and obtain forecast.

• Did recognize condition, but did not apply this recognition to tactics.

• Knew about Red Flag issued at 0623 hours (08/11); did not know about the Red Flags issued at 1200 hours, but this did not contribute to the accident because there was no change in the Red Flag for the local zone (287).

*4. Ensure instructions are given and understood.

• unclear instructions on burn out in Mexican Pass area

• unclear instructions on who was in charge in Mexican Pass area

*5. Obtain current information on fire status.

• Lack of incident management organization led to incomplete fire intelligence.

*6. Remain in communication with your crew members, supervisors, and adjoining forces.

• No radio communications with the Hot Springs engines.

*7. Determine safety zones and escape routes.

• Knew that safety zone was in the black, and the escape route to it.
• Escape route was compromised because Engine #2 got in front of unburned fuels.

*8. Establish lookout in potentially hazardous situation.

• Did not have a designated lookout posted.

*9. Maintain control at all times.

• No one designated as being in charge at the Mexican Pass area

10. Stay alert, keep calm, think clearly, act decisively.

• Did not contribute to the fatality.

• Quick response of the crew of Hot Springs Engine #7 probably prevented more serious injuries to Presley Byington.

18 SITUATIONS THAT SHOUT WATCH OUT     
Seven (7) Were Present

1. Fire not scouted and sized up

• Oklahoma Engine #2 was in the process of sizing up this portion of the fire when the entrapment occurred.

2. You are in country not seen in daylight.

• This was not a contributing factor.

3. Safety zones and escape routes were not identified.

• Crews understood and demonstrated that the burn area was their safety zone.

• Burned over engine could not get to safety zone because the escape route was compromised.

4. You are unfamiliar with weather and local factors.

• Engine #2 had been working in similar fuels and weather for at least one (1) week.

*5. You are not informed of tactics, strategy and hazards.

• Unclear direction on tactics in the area
• No overhead assigned to this segment of fire.

*6. Instructions and assignments are not clear.

• Engine #2 knew they were to support the dozer line, but they were uncertain as to the location of their assignment and the role they would have.

*7. No communication link has been established with the crew members and their supervisor.

• Communications were established within the Oklahoma crews.

• Handheld radios were set to Agency frequency.

• Communications with supervisors were subject to the availability of the human repeater.

8. You are constructing line without a safe anchor point.

This was not a contributing factor

9. You are building fire line downhill with fire below.

• This was not a contributing factor

10. You are attempting a frontal assault on the fire.

• This was not a contributing factor

*11. There is unburned fuel between you and the fire.

• There was unburned fuel between Engine #2 and fire while the crew was scouting out control lines.

12. You cannot see the main fire and are not in contact with someone that can.

• This was not a contributing factor

13. You are on a hillside where rolling material can ignite fuel below you.

• This was not a contributing factor

14. The weather is becoming hotter and drier.

• This was not a contributing factor

*15. The wind is increasing or changing direction.

• Wind speeds suddenly increased as a dry surface cold front passed.

• Engine #2 knew winds were expected to increase but were not fully cognizant of the relationship to their location and the resulting fire behavior.

*16. You are getting frequent spot fires across the line.

• There had been difficulty in holding the fire to control lines prior to Engine #2's arrival.

*17. The terrain and fuel make escape to safety zone difficult.

• Narrow road and terrain made turning the engine around difficult.

18. You feel like taking a map near the fire line.

• This was not a contributing factor.

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