P-515 Accident

Investigation Warm
Springs Agency

August 18, 2020 at 20:03 hours

Executive Summary:

On August 18, 2020 at approximately 19:45 hours, a van sustained minor burn damage and a pickup truck was
completely burned on the Warm Springs Agency P-515 Incident near Madras, OR. The vehicles were parked
next to heavy, unburned timber, along with two other vehicles belonging to a Type 2 crew. The crew was
suppressing spot fires on the east side of the incident when the fire behavior increased and threatened the
vehicles. The crew boss and safety officer were nearby and began moving the vehicles to a safer location.
Two vehicles were moved without issue, but the fire had reached the van and pickup truck by the time the
crew boss and safety officer returned. The crew boss was able to move the van, but its tail light was on fire
and the left rear corner was scorched. The tail light was extinguished and the damage was repaired the next
day. The pickup truck could not be moved because the left rear tire and driver’s side door handle were on
fire. It was soon completely involved and was a total loss. There were no firefighter injuries from this
incident.

Critical Incident Stress Management (CISM) services were offered immediately. An interagency accident
investigation team was ordered on August 19th and in-briefed on August 21st.

The following narrative is intended to meet DOI accident investigation requirements and provide
recommendations which can be used to prevent similar events from occurring.

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 Narrative:
The P-515 fire was started by lightning on the evening of August 16, 2020. This lightning event caused many
other fires in the western US, so resources were immediately scarce. By August 18th, a local Type 3
organization was managing
P-515 and an order for a Type 2 Incident Management Team had been placed. Fire behavior was described as
high to extreme, with frequent crowning and spotting occurring most of the day of the 18th. By that evening, the
fire had surpassed the 3-day WFDSS fire behavior growth predictions.

Above photo represents projection model of fire spread on days 1-3. Below photo represents actual fire spread (yellow: 8/18 fire perimeter
at 1700 hours at 772 acres and red: 8/19 fire perimeter at 22:00 hours at 2,326 acres)

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The general strategy on the afternoon of the 18 was to hold the fire west of the P-500 road. Two interagency
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hotshot crews (IHCs) had been working on the northern flank of the fire earlier in the day but had withdrawn
at approximately 16:00 hours due to fire activity. By 18:30 hours, the potential was high for the fire to cross
the P-500 road. Incident overhead decided to conduct a burnout, in an attempt to slow the fire’s progression.
The burnout was conducted by two IHC overhead. The fire spotted across the P-500 road at approximately
19:06 hours and aligned with the west winds and topography. This caused the fire to burn into a logging unit
along the P-600 road. Once the fire hit the logging unit, it lost alignment and fire behavior decreased.
Encouraged by this change in fire behavior, resources then attempted to suppress spot fires in the logging unit
and keep the fire south of the P-600 road. This included a Type 2 hand crew and Strike Team of engines. The
IHCs did not engage in suppression efforts along the P-600 road.

The Type 2 Crew was assigned by the Division Supervisor to suppress spot fires at the P-500/P-600
intersection. They arrived at that location approximately 19:30 hours. To allow for egress, they parked their
four crew vehicles along the road next to a triangle of green timber, at the intersection. The crew boss parked
his vehicle just around the corner on the P-500 road, facing north, as did the safety officer. The crew went
right to work on 3-4 spot fires, the largest about 20’ x 30’ in size, beginning approximately 150 feet into the
logging unit from their vehicles. The crew boss also contemplated brushing the road, but ultimately did not
have time.

The triangle of timber at the intersection and the southern edge of the P-600 road just south of the crew had
not yet burned. Heavy mixed conifer obscured the view of the main fire from the crew. There is a slight saddle
in the topography from the road intersection to about a tenth of a mile east on the P-600 road. This saddle may
have been obscured by the timber and may not have been visibly obvious until after the timber burned and
likely contributed to the rapid spread of the fire towards the vehicles.

Air attack photo of the fire at 19:17 hours. Photo taken from north/northwest of fire, facing east/southeast. The fire is burning east with
the smoke column leaning over the P-500/P-600 road intersection.

Photo of northeast corner of fire, taken by helicopter at approximately 1700 hours on 8/18, day of incident.

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 Photo of the Northeast corner of fire, taken by helicopter at approximately 17:00 hours on 8/18, day of incident.

The crew had been working approximately 10 minutes when a crew member noticed a glow from the main fire,
south of the P-600 road. He relayed this to the crew boss, who, along with the safety officer, was closer to the
vehicles. The crew boss and safety officer decided to move the vehicles to a safer location and relocated the
first two vehicles in front of their own, on the P-500 road. This took less than five minutes. They ran the short
distance back to the triangle, but found the remaining two vehicles already impacted by flames when they
returned. The crew boss was able to move the front vehicle, a van, but its tail light was on fire and the left rear
corner was scorched. The last vehicle, a pickup truck with camper shell, could not be moved because the left
rear tire and driver’s side door handle were on fire. It was soon completely involved and was a total loss.

Once the vehicle fire was reported, all resources were directed to retreat to their safety zones and the effort to
hold the P- 600 road was abandoned. There were no firefighter injuries from this incident.

Investigation Process:
On August 21, 2020 the Interagency Accident Investigation Team in-briefed at the incident command post for
the P-515 incident. A Delegation of Authority to conduct the investigation was approved and signed by the
Agency Administrator and received by the Team Lead. The investigation process included, interviews, a site
visit to the scene of the incident, review of documentation, examination of the burned vehicle and a fire
behavior analysis of the day of the incident.

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Findings:
F 01: Four crew vehicles were parked in an area of unburned fuel. The fire moved at a higher rate of
spread than expected and two of the four crew vehicles were damaged, one being a total loss
due to fire.

F 02: A dedicated lookout was not assigned to monitor the main fire in relation to the crew’s position.

F 03: No spot weather forecast had been received for August 18th and no weather observations were being
recorded or announced to all personnel on the incident.

 A spot weather forecast was requested at 14:00 on August 18 , however it is unknown if this request
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was processed.

F 04: Trigger points were not well defined and known by all personnel.

F 05: The Division Supervisor, Incident Commander Type 3 (ICT3), ICT3 trainee, and the Operations AFMO
were all tactically engaged on the division.

F 06: The crew was assigned to a section of the fire without identified anchor points, during a time when
frequent spot fires had been occurring for several hours.

F 07: Documentation was extremely limited; a lack of incident organizers, unit logs, notes, dispatch logs,
etc. creates difficulty in determining the events that occurred during an incident.

F 08: A number of Fire Orders and Watch-out Situations were identified as key factors to the incident.

 Keep informed on fire weather conditions and forecasts.

 Know what your fire is doing at all times.
 Base all actions on current and expected behavior of the fire.
 Post lookouts when there is possible danger.
 Maintain prompt communications with your forces, your supervisor, and adjoining forces.
 Fight fire aggressively, having provided for safety first.
 Constructing line without safe anchor points.
 Attempting frontal assault on the fire.
 Unburned fuel between you and the fire.
 Cannot see main fire; not in contact with someone who can.
 Getting frequent spot fires across the line.

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Recommendations:
R 01: A dedicated lookout, posted in a location to assess the threat of the main fire in comparison to
personnel, is key to the early alert of unexpected fire behavior.

R 02: Weather observations should be documented and turned in to the incident management, and
included in documentation for the incident. Frequent weather observations, taken and relayed to
personnel on the incident serve to increase situation awareness.

R 03: Vehicles should be parked in a safe location.

R 04: Develop a programmatic documentation plan to capture all relevant data during suppression efforts.
This can be submitted and reviewed for all incidents regardless of complexity. Use of the Incident
Commander’s Organizer (NFES 2906) and Unit Logs (ICS 214) or equivalent documentation is
recommended. Unit logs should be maintained by all single resource bosses.

R 05: Spot weather forecasts should be obtained as early as possible during extended attack incidents.

Commendations:
C 01: Immediate determination was made to leave the burning vehicle and get the crew and vehicles to a safe
location.

C 02: Support, by incident and agency management, assisted in the crew’s ability to efficiently and safely
return to work during the following shift.

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Conclusion:
Although no injuries occurred, this incident highlights how quickly fire conditions can escalate resulting in
hazardous conditions to personnel. The Type 2 crew made the decision to park their vehicles in close
proximity to their work location as the vehicles were their mode of escape if needed, yet fire behavior
increased at a rate preventing the crew to relocate all their vehicles to a safe location. Upon loss of one
vehicle, it was necessary for additional resources to provide safe transport for part of the crew. Ultimately,
two of the crew’s five vehicles were damaged during the incident, one being a total loss. This scenario can
help frame very useful discussion about “engagement”, “disengagement”, and what “fight fire aggressively”
actually looks like and the risk trade-offs it sets up.

In order to effectively determine an appropriate level of engagement, operational roles and expectations must be
clearly defined. Chosen tactics should be based on current and predicted fire behavior, incident objectives,
probability of success, and an in-depth assessment of risk. In addition to all that, we must be weary of “sunk
cost bias” which can lead us to continue investigating in an approach that is not succeeding.

Incident overhead failed to recognize that their strategy had a low probability of success and adapt their actions
accordingly. Consider additional tactical decision making training for fire overhead, such as Mission Centered
Solution’s Intent Based Planning (mcsolutions.com).

It is the opinion of the investigation team, resources should not have engaged at the location and time this
incident occurred. “Mission Focus,” may have contributed to engagement at the P-600 road.

There may be a stigma within the contract firefighting community about properly refusing risk. Incident
personnel on the P-600 road may have been uncomfortable turning down the assignment, because they were
contractors and are required to have performance evaluations completed on every assignment. This raises the
notion of “The Contractors Dilemma” link: https://www.podbean.com/media/share/pb-ryw9r-
63572e?utm_campaign=u_share_ep&utm_medium=dlink&utm_source=u_share

All resources have the right to properly refuse risk, aka Turn Down Protocols (IRPG pg. 19).

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Investigation Team:

Troy Phelps, Team Lead

Occupational Health and Safety Program Manager
BIA – Rocky Mountain Region
troy.phelps@bia.gov

Eric Fransted, Team Member

Wildland Fire Safety Program Manager
U.S. Fish & Wildlife Service, Branch of Fire Management
edward_fransted@fws.gov

Jade Martin, Team Member

Fire Equipment Specialist, National Fire Equipment Program
NIFC-BLM
jlmartin@blm.gov

Bob Arnsmeier, Team Member

Contract Officer
Oregon Department of Forestry
bob.arnsmeier@oregon.gov

Adrian Grayshield, Team Member

Safety Program Manager
BIA – Branch of Wildland Fire Management
adrian.grayshield@bia.gov

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Appendix A – Photo Log

Pre-burn photo of “the Triangle”

P-500 road fire activity, approximately 18:30

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P-600 road looking east, post fire. Burned pickup truck is at the start of a triangle; the
other vehicles were moved in front of the white pickup truck. The harvested timber
unit is on the right.

Burned pickup truck viewed from the south side of the P-600 road, looking north. The
other vehicles were moved in front of the white pickup truck.

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Close-up of damage to pickup truck

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Appendix B – General Weather RX

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Appendix C – Perimeter Map

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Appendix D – 72 Hour Report

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