APPENDIX A

Figure A.1 GENERAL OVERVIEW FOR EVALUATORS


Enclosed;

  1. Overviews of each accident investigation method a) Fault Tree Analysis, b) Control/Barrier Analysis, c) STEP (Sequential Timing and Events Plotting).
  2. Results of the South Canyon case study analysis using the three methods. If the results seem incomplete and need something added, let me know...I may have missed something in the analysis as I have had no one look it over. That doesn’t necessarily mean the analysis method is faulty, just my work to produce the results!
  3. Study Approach copy with the evaluation criteria and rating procedures. Rate each method using the 6 criteria (ranges 0 to 2). Therefore a method that fully meets each criteria would have an overall rating of 12. The study approach has a brief history of the fire, the criteria and procedures I used and the scientific justification for using the case study approach (This part isn’t necessary to read to do the evaluation). Enclose any additional comments or suggestions that may be helpful. Also if at any time there are questions about any area, call or e-mail me at the following;
Steve Munson
508 S. 3 rd W. #9
Missoula, MT. 59801
406-5423877

INSTRUCTIONS:
Each criterion will have to be evaluated as to how it would apply to field investigations of wildland firefighter entrapments. Therefore, for example, for criteria #4(consistency), you need to assess if this method is repeatable if someone else had the same information, did it seem to be a logical method to determine all the causal factors involved? Remember that you are to evaluate each accident investigation method, not how well I did it, but what each method reveals as far as contributing and causal factors. If one method does not look deep enough into a cause, then it may not be comprehensive enough, (but that method may be able to do that I just didn’t pursue it far enough) that’s my fault not the methods.
Please return your results as soon as possible. All this needs to be is the number assigned to each criteria (i.e. Realistic-1, comprehensive-2) for each method...STEP, Fault Tree, and Control /Barriers. Also enclose any comments and suggestions you may have that would aid in making the study or technique(s) better.

GENERAL COMMENTS ON EACH METHOD:

Fault Tree Analysis—the top event is the undesired happening (getting burned over) work down the tree in steps to determine what caused the event above it. If two or more events are required then an “and” gate is required. If only one of a list of events is required then an “or” gate is necessary. Keep working down until you found the root cause or you don’t have the information to go any further.
Control/Barriers Analysis—There are always barriers to protect us from harm. When one or more fail then an accident can occur. These barriers can be physical (PPE) or administrative (Rules, guidelines, etc...) The idea is to define the barriers that protect firefighters from getting burned over, then assess which ones failed.
STEP- The idea is to reproduce the accident sequence as a mental motion picture. You use blocks that define actors and their actions that together or alone interacted to produce an accident. Actors can be people or things (Fire is an actor). You place these blocks along a timeline to determine gaps, the accident flow, and the interaction between actors (and their actions). This gives a visual means to reproduce the accident and what caused what to happen and when. In this study an Excel worksheet was used to show all information available and the relevant actors along a timeline. The blocks were taken from that worksheet to produce a flow diagram that shows how the accident process occurred.


TABLE A.1

Barriers Worksheet


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Figure A.3 STEP WORKSHEETS

The following pages are the STEP development worksheets. They were constructed in a Microsoft Excel spreadsheet program and are made up of STEP building blocks (see Figures 13-14) along a timeline on the X (horizontal) axis. The Y (vertical) axis lists the actors (people, objects, things) in the accident sequence. These worksheets are placed so that they are read across to the final outcome and then drop down and read across again. The sources of information were abbreviated due to limited space. They are 1) FBA is for the fire behavior analysis done by Butler and others (1998) which includes Ted Putnam’s time estimations, 2) SCR is for the original South Canyon Report (IMRT 1994, 1995), and the 3) OSHA report (1995) was also a source of information.
 
TIME
300:00:00
5:28:00
08:00 to 09:00
9:30:00
10:27:00
11:15:00
11:30:00
Actor







FIRE
 
SCR,Rhoades


"Fire"burning actively




SCR


"Fire" produces smoke low in West drainage


-SCR-
"Fire" runs 5ft. Strip from torched tree 40 yds down from ridge..causes spot fire across line, water drop and crew suppress.

WIND







SPOT FIRE(1)East






SPOT FIRE(2)West






WEST FLANK GROUP









11:35:00
12:30:00
12:45:00
13:00:00
13:30:00 PM
14:00 PM
14:15 to 14:30
14:45:00
15:00:00









Petrilli,Doehring


"Fire" torches Tree 40yds. below Main Ridge, 5ft.wide run through oak


SCR
"Fire" flares up at Tree..firefighters retreat 400ft. Then return when water drops effective.


Scholz,Shepard

"Fire" activity increases...Smoke low in canyon.Wind increases on Main Ridge

SCR

"Fire" burning as hot spots in double draws.








-Scholz-

"Wind" blows strong and gusty at Canyon Cr. Estates(15mph)...front approaches
-Scholz, Shepard-

"Wind" increases on Main Ridge...fire activity increases
























-Scholz-

"West Flank Group" meets at Stump...first time together
- SCR-

"West Flank Group" eats lunch with Jumpers at Lunch Spot




15:15:00
15:20:00
15:23:00
15:30:00
15:45:00
15:55:00
15:56:00
15:58:00








SCR

"Fire" activity picks up west of H1...reported by helibase



SCR, Scholz,Erickson,Doehring

"Fire" burning in litter...
-Petrilli, Longanecker

"Fire" activity continues south of Double Draws





-SCR-
"Wind" squirrely at H-2...light at Zero Pt.
Cold Front approaches

Scholz-
"Wind" blows strong on Main Ridge...calm on West flank...picks up on Lunch Spot...sun breaks through

Ryerson,Good,Shepard photo-
"Wind" blows at 35mph on Main Ridge and South of Lunch Spot...Calm on West flank

Erickson,Doehring
"Wind" calm on west flank







-Good-
"Spot fires" burning in bottom of West drainage







Good-
"Spot fires" burning in bottom of West drainage





-FBA-
"West Flank Group" working between 1450ft and 1880ft from Zero Pt.





16:00:00
16:02:00
16:04:00
16:05:00
16:06:00
16:07:00
- -SCR-
"Fire" crosses west drainage at base of gully below Longanecker

Doehring,Erickson,Brixey,Haugh-
"Fire" moving north up drainage

Erickson,Hipke-
"Fire" active in bottom of West drainage south and below Lunch Spot.

-- -- Good,Ryerson-
"Fire" intensity increases



Petrilli,Thomas,Shepard-
"Fire" runs up east facing slope in West drainage...moving north.
- -- Hipke,time:Putnam-
"Fire" on west bench north of Lunch spot."U" shaped front up both sides of drainage

-Scholz-

"Wind" blows from west at 45 mph


-Petrilli-
"Wind" blows at
35mph below Lunch Spot.
Petrilli radios Mackey that fire has crossed main
canyon
.
Good,Ryerson-
"Wind" blows from
west @45 mph
on Main ridge



-Petrilli-
"Spot fire (1)" runs on East-facing slope...35 yds. North of Double Draws



-Shepard,Scholz-
"Spot Fire(2)" starts
across West drainage
below West Flank Group.
Reported by Kelso...Scholz
"things are getting complicated"





Shepard,Scholz-
"West Flank Group" told by
Shepard to "get out"
1880 ft. from Zero Pt
.




16:11:15
16:12:00
16:12:15
16:12:30
16:13:30





Erickson,Archuleta,Time:Putnam-

"Fire" roars up to Main ridge south of Spur Ridge

Time:Putnam -FBA-

"Fire" burns to base of spur ridge about to enter draw below "tree"

Scholz-

"Fire" on south side of Spur Ridge crests Main ridge 150-200ft. South of Zero Pt.

Time:Putnam-
-Erickson,Haugh,Scholz,Robertson-

"Fire" crests spur ridge
hot air, heat @Zero Pt.


TIME:Putnam -FBA-

"Fire" burns over West Flank Group
200-280 ft. from Zero Pt.



















Time: Putnam -FBA-

"West Flank Group" stops @200ft. From Zero Pt. Leaders
Thrash&Roth Depoy Shelters

Time: Putnam -FBA-
"West Flank Group" overrun by fire 200-280ft. from Zero Pt.


16:13:45
16:14:00
16:15:00



Time:Putnam-

"Fire" overruns Blecha at 121 ft. from Zero Pt.



Hipke, time:Putnam-

"Fire" just about at Zero Pt. Hot air pushes down Hipke 15ft. From Zero Pt.

Navarro,Scholz Byers,Ryerson, time:Putnam-

"Fire" near top of Main Ridge at H-2
















TIME
300:00:00
5:28:00
08:00 to 09:00
9:30:00
10:27:00
BLANCO


-SCR-

"Blanco" with BLM/FS crew at Main ridge, begin making H-2. Discusses strategy with Mackey. Listens to NOAA forecast with some jumpers.
-SCR-

"Blanco" with Mackey,Tyler, and 93R recons fire. Mackey calls jumpers on ground and instructs to build line down West flank.

ERICKSON

Erickson,SCR-

"Erickson" went to get gear at jump spot.

-Erickson,SCR,FBA-

"Erickson" "thought it looked ugly down in there" when told to start digging line downhill

RHOADES



-Rhoades,OSHA-

"Rhodes" questions downhill line construction...Jumper'(2) load dropping
JUMPERS(1)

-Rhoades,OSHA-
"Jumpers" talk about whole drainage burning out, move to jump site to gather gear.
-SCR-

"Jumpers(1)" questions downhill line construction and requests discussion with Mackey...smoke low in west drainage

JUMPERS(2)



-SCR-

"Jumpers(2)" of 8 arrive...little wind...fire at 127 acres
PRINEVILLE IHC(9)






16:04:00
16:05:00
16:06:00
16:07:00
16:08:00
16:08:30
16:08:40
16:10:00
16:10:30
-Scholz,Gray, SCR-

"Blanco" relays message about Spot fire across West drainage to Ryerson, Mackey

-Doehring,Erickson,
Brixley, Haugh-

"Blanco" called by Haugh about Spot fire(2) across West drainage...says "get out"







-Erickson,Doehring-

"Erickson" with Doehring meet Archulta on west flank about 450ft.and hear order to get out

Erickson,Doehring, Haugh, Brixey-

"Erickson" Doehring, Archuleta at Tree...meet Haugh,Brixey,,.


-Haugh,Erickson,time:Putnam-

"Erickson"sees first of West Flank group crossing top of Spur Ridge. At Tree with Haugh


FBA:Time:Putnam
"Erickson" at Tree, sees West Flank Group as they cross Spur Ridge...yells at Group to go faster, calls Mackey about spot fire(2) below








































16:10:45
16:11:00
16:11:15
16:12:00
16:12:15
16:12:30
16:13:30
16:13:45
16:14:00
16:15:00

-SCR,FBA-
"Blanco" radios Dispatch and says they are losing fire on side near homes(east side of west drainage)...requests retardent.










Erickson,Archuleta Time:Putnam-

"Erickson" with Haugh start up fireline...Hipke at 325ft. From Zero Pt.

















































 
 
TIME
3:00:00
5:28:00
08:00 to 09:00
9:30:00
10:27:00
11:15:00
11:30:00
11:35:00

PRINEVILLE IHC CREW









MACKEY

-SCR-

"Mackey" request Helicopter and fixed wing aircraft.


-SCR-

"Mackey" takes recon flight in 93R with Blanco, Tyler. Tells Jumpers(1) to dig line down West flank








12:30:00
12:45:00
13:00:00
13:30:00 PM
14:00 PM
14:15 to 14:30
14:45:00
15:00:00
15:10:00
15:15:00
15:20:00


OSHA,Haugh-


"Prineville" briefed on weather, frontal passage at helibase?






-SCR-
"Prineville"(2nd group) arrive at H-2..works on Main ridge...Longanecker leaves Lunch spot to scout line to South




15:23:00
15:30:00
15:45:00
15:55:00
15:56:00
15:58:00
16:00:00
16:02:00
16:04:00
16:05:00








-SCR-

"Prineville"on main ridge directed to go to H-1 to safety zone.


-SCR,Erickson,Doehring_

"Mackey" sends Erickson,Doehring to hotspot Main ridge





-Petrilli-

"Mackey" called by Petrilli to report fire is 35yds north of base of Double Draws.




16:06:00
16:07:00
16:08:00
16:08:30
16:08:40
16:10:00
16:10:30
16:10:45
16:11:00
16:11:15
16:12:00











-Petrilli, Thomas,Shepard-

"Mackey" meets Jumpers(2) 100ft. Below Lunch Spot,says to go up to H-1. Calls Longanecker to check up.
-Longanecker,time:Putnam-

"Mackey" moves north toward West Flank Group after radioing Longanecker.
Time:Putnam-

"Mackey" begins running north along West flank fireline at 1450ft.

-SCR-

"Mackey" catches up with West Flank Group.


-Erickson-

"Mackey" called by Erickson about spot fie below them






16:12:15
16:12:30
16:13:30
16:14:00
16:15:00











































Note: “Prineville IHC (9)” and “Mackey” during these time frames were in the process of being overtaken by the fire.

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