By the beginning of this summer, the drought that had been plaguing the American Southwest for a decade made the air feel like a blast furnace. The dry, hot air was especially notable during the last week of June. Despite the heat, the foothills northeast of Phoenix provided a tempting pull from the pulsing life in the big city, and a respite from the overbearing heat of the Sonoran Desert to the south. There were many unique finds for a wandering hiker or local resident in the northern Arizona town of Yarnell: boulders painted to look like an elephant, a frog or a skull; the Shrine of Saint Joseph of the Mountains; the remains of mines that helped build the city and of the ghost towns that followed; and on June 28, a wisp of smoke hovering above the small town.
Within hours, 20 wildland firefighters from the fire department in Prescott, Ariz., were hiking into the hills near Yarnell. Located approximately 30 miles north of Yarnell, the city of Prescott had designed an innovative way to address the increasing danger of fires in the wildland/urban interface: the Granite Mountain Hotshots.
Despite their familiarity with the hazards inherent to the area, on June 30, the Granite Mountain Hotshots would be involved in the greatest tragedy to hit the emergency response world since the events of September 11, 2001. The result was 19 firefighters killed in the line of duty, countless families and friends trying to find a way to move on, and many communities looking for answers.
At the time of the incident, the long-term drought that had plagued the region had created an extreme fire danger situation. High temperatures, combined with low fuel moisture and high fuel loading, caused the Southwest Coordination Center to issue a "Fire Behavior Advisory" on June 16. Then, on June 25, the National Weather Service issued an excessive heat watch for Arizona's lower elevations.
The Yarnell Hill Fire was sparked by lightning on June 28, and was determined to be about one-half acre in size when the first crews arrived. Due to the dangerous conditions, no firefighters were placed on the fire on the first day. A local Type 4 incident commander (ICT4) assumed control of the fire, and on June 29, local resources began to engage in firefighting operations.
For most of the day the fire seemed insignificant, and resources were even being released. However, starting about 1600 hrs, the fire began growing rapidly, causing new concern, and a Type 2 incident management team (IMT) was requested. Members of the IMT began to assume management of the fire on June 30. At the same time, the Granite Mountain Hotshots also began their assignment on the Yarnell Hill Fire, estimated to be approximately 300–500 acres in size on the morning of June 30.
As is often the case with resources arriving early in a fire, Granite Mountain was asked to perform multiple roles at the in-briefing. Of note, their Superintendent Eric Marsh was asked to be Division Alpha Supervisor (DIVS A), and to establish an anchor point at the heel of the fire with the Granite Mountain Hotshots.
For most of the day, the fire spread to the northeast. DIVS A and Granite Mountain began their assignments—parking their crew buggies in a mid-slope clearing, scouting where to create an anchor point for their firefighting operations, and leaving one of their members at a lookout point from which he could observe the Granite Mountain crew, the fire and their surroundings. The practice of placing a lookout in such a fashion is one that is required of all resources engaged in wildland/urban interface firefighting. Specifically, "LCES" requires posting a lookout, ensuring consistent communications, establishing an effective safety zone to which crews can retreat should conditions worsen, and identifying escape routes upon which the retreat can be made.
After spending the morning establishing responsibilities, scouting and setting up for an afternoon of firefighting operations, the Granite Mountain Hotshots found an area where they could have lunch—a location that will later be referred to as the "lunch spot."
Throughout the afternoon they worked to establish an anchor point and create a fireline to the north. However, changing weather conditions (predicted by the National Weather Service and relayed in at approximately 1400 and 1530 hrs) were creating erratic fire behavior, and the active fire had moved away from where the Granite Mountain crew was working.
Understanding the significance of the weather reports, the operations chief in charge of the Yarnell Hill Fire checked to make sure Granite Mountain had heard the reports and was in a safe location. Having confirmed that, the operations chief switched his focus back to the active fire advancing directly on the communities of Peoples Valley and Model Creek. Meanwhile, DIVS A and Granite Mountain continued their work.
Shortly before 1600 HRS, the Granite Mountain lookout noticed that the wind had changed direction and, as a result, the fire was beginning to build to the east. Following instructions, the lookout reported that the fire's previously established trigger points had been reached, and that he had to relocate for safety. The lookout encountered the superintendent of another hotshot crew working nearby (Blue Ridge), and was given a ride to the Granite Mountain crew buggies.
As the lookout and members of the Blue Ridge Hotshots moved the Granite Mountain buggies to a better location, the Blue Ridge superintendent confirmed with Granite Mountain that they were still "in the black" (referring to burned area generally considered to be free of unburned fuels that might cause risk). In response, DIVS A stated, "I want to pass on that we're going to make our way to our escape route." While there was some confusion between DIVS A and Blue Ridge, it seems as if both were under the impression that Granite Mountain and DIVS A were still safely in the black.
Resources in other locations were not only conducting structure protection, but they were also being relocated and evacuated due to increasing and shifting fire activity.
As the fire entered Peoples Valley and Yarnell, aerial resources continued to provide protection from above. At approximately 1600 hrs, an Air Support Module (essentially an air traffic controller) overheard someone say, "We're going down our escape route to our safety zone," and asked if everything was fine. The message was apparently from DIVS A, who responded, "Yes. We're just moving."
Then at approximately 1640 hrs, these horrible words were broadcast: "Granite Mountain Hotshots. We are in front of the flaming front." After some attempts to clarify the significance of that last communication, the message was followed by, "Our escape route has been cut off. We are preparing a deployment site." With chainsaw heard in the background, then, "I'll give you a call when we are under the shelters." Air Support asked, "You're on the south side of the fire?" to which DIVS A yelled "Affirm!" This would be the last word heard from the Granite Mountain superintendent.
After hearing of their possible deployment, operations immediately began trying to locate the Granite Mountain crew. Ground crews began a search, and the circling DC10 (a very large airtanker or VLAT) was told to hold a drop for Granite Mountain protection if they could be located. Unfortunately, attempts to locate them were unsuccessful until 1810 hrs, when their deployment site was located by an Arizona helicopter crew.
The crewmembers were found approximately one mile south-southeast of their last known location, approximately 600 yards west of the Ranch. At 1835 hrs, a paramedic with the Arizona helicopter crew confirmed that all 19 of the Granite Mountain Hotshots had perished. (The lookout was safely moved earlier.)
The State of Arizona convened a Serious Accident Investigation Team (the "Team") on July 3. The Team, which consisted of members from local, state and federal agencies, as well as experts from related industries, was tasked with reviewing the circumstances that led to the entrapment and deaths of the 19 firefighters. I was asked by the Lead Investigator to be a subject matter expert for the Team as a representative of the local fire service.
The Team reconstructed events through a variety of methods and data sources, and conducted more than 65 interviews with firefighters, fire support personnel, leadership personnel and members of the public. The Team also gathered photos, videos, audio fragments, maps, dispatch logs, incident documentation, weather station records, and training records, and conducted site visits, equipment analysis, and wind and fire behavior modeling.
There is a 33-minute period of time during which nobody is sure where the Granite Mountain crew was or why they made the decisions they made. From 1604 to 1637 hrs, there is no record of Granite Mountain's status. The Team noted three phases worthy of discussion related to that block of time:
Phase 1: Their movement southeast, down the two-track road from the lunch spot, beginning at approximately 1604 hrs. At this point Granite Mountain left the black. It is not clear why they chose this option, considering the alternatives, but the best guess is that they did so to position themselves for the opportunity to re-engage in a seemingly more relevant role later in the fire.
Phase 2: Their descent from the two-track road through a box canyon toward Boulder Springs Ranch. From where they chose to descend off the ridge, many people commented that the Ranch appeared much closer than it actually was. Perhaps they chose to leave the two-track road because it looked like that would be a quicker route through the unburned brush in the box canyon. Although their ultimate goal remains unclear, one can guess that their intent was to get to the Boulder Springs Ranch.
Phase 3: At some point in their descent off the two-track road, their view of the fire became totally obstructed by a ridge and boulder pile to the northeast. During this time they were also unable to see changes in the smoke column, wind direction, fire spread and fire intensity. Once they reached a small opening in the brush, they most likely realized that the fire had rapidly pushed to the south, and that the flaming front had cut off their escape route from the box canyon. At that point the only viable option was to try to survive by deploying their fire shelters. We know they were preparing for shelter deployment at approximately 1640 hrs.
Due to the lack of information about what happened during those critical 33 minutes, it is difficult, if not impossible, to identify concrete lessons learned from the actions of the Granite Mountain crew. The Team did not want to draw conclusions based on speculation in a matter this important, where highly trained, experienced firefighters made decisions that resulted in their deaths. It is easy to say their decision to leave the black was a poor one, but we say this knowing only the end result, not all the factors that influenced that decision. In examining the information that was obtained related to the fire, however, the Team was able to draw some general conclusions that might improve firefighter safety in the future:
- 1. The Yarnell Hill area was prime for fire because of the extreme drought it had been experiencing, combined with an increased fuel load (due to the lack of wildfire for more than 45 years). By promoting fuels management, safer conditions might be ensured, even during a drought.
- 2. Many structures in the area were not defendable. Principles such as those in the Ready, Set, Go! and Firewise programs could guide homeowners in creating fire-resistant homes and communities.
- 3. The fire's complexity was rapidly changing, resulting in frequent transitions. As an example, the fire went from a Type 4 to a Type 1 IMT in a period of 20 hours. Increased care must be taken during the transitional phases as they are widely known to be dangerous and to increase the "fog of war."
- 4. The Granite Mountain crew had been watching the fire all day long, but as they descended off the two-track road, they lost sight of the fire and all of the indicators of directional and intensity changes. Because their lookout had (rightly) moved, they were lacking a lookout and proper situational awareness. This confirms the importance of ensuring proper lookouts, communications, escape routes and safety zones (LCES).
- 5. The Team found nothing to indicate that there was a specific reason for the Granite Mountain crew to leave the black, but concluded that they perceived no increased risk by moving toward Boulder Creek Ranch. It can only be guessed that they did so in an attempt to re-engage elsewhere. Everyone who provided information in the investigation reported being confused about the whereabouts of the Granite Mountain crew, and most thought they were safely in the black until the report of their deployment. The importance of following through with assignments, or communicating the inability to follow through, cannot be overestimated.
- 6. Granite Mountain was a fully qualified, staffed and trained hotshot crew per the Standards for Interagency Hotshot Crew Operations. Everyone was working within their scope of duty.
After outlining the narrative using the available data, the Team sought to compile a number of discussion points regarding the unknowns of the Granite Mountain fatalities. These are not answers; rather, they are questions designed to inspire discussions in recognition that everyone's approach might be different. Perhaps the most valuable lessons lie within these discussions.
Situational Awareness: This is the process by which people make sense of what is happening around them. The Team believes that when the crew left the lunch spot to travel down the two-track road, and then took a direct route to Boulder Springs Ranch, they were trying to reposition, perhaps because of a "culture of engagement" and "bias for action" that is part of the success of the firefighting culture. It is possible that the crew believed the first change in weather that they observed was the whole predicted change, which was not the case.
Questions for discussion:
- How do we make weather updates relevant?
- How long do we keep them in mind?
- In these times when extreme conditions are the norm, are we becoming desensitized to extreme conditions and the hazards they bring?
Fireline Safety: The black is generally thought to be a safety zone, and there is no indication that the Granite Mountain crew left the black because they, or anyone else, thought they were in danger. Further, there is nothing that indicates that the crew perceived any additional risk while repositioning to the Boulder Creek Ranch. It is important to understand that it is necessary to identify escape routes and safety zones that are reasonable for the conditions. It is clear that the lack of a lookout compromised the safety of the Granite Mountain Hotshots, as they lost sight of the fire as they descended off of the two-track road.
Questions for discussion:
- What constitutes a good escape route? A good safety zone?
- When should a lookout be posted?
Communications: There was considerable confusion about where the Granite Mountain crew was going once they moved, despite attempts to get answers. The need for short and concise messaging on fires might lead to a lack of understanding of the message, including where you are and what you need.
Questions for discussion:
- How much detail should we provide to others to help them see our picture?
- Can people elsewhere help us assess our risk?
- What is the best way to make sure we have received the information we need to be useful?
Incident Organization: As with most expanding fires, there was rapid organizational growth and increasing complexity during the Yarnell Hill Fire.
Questions for discussion:
- What are some of the things that can be done to reduce confusion as incident escalation occurs?
- What communication strategies might help firefighters and ICs promote more collective (rather than individualized) sense-making?
Foresight vs. Hindsight
The incident at Yarnell Hill, and the tragic deaths of the 19 Granite Mountain Hotshots, will forever leave people searching for answers. There will be those who complain that this report does not satisfy that need, arguing that there are still too many unknowns. The Team hoped to be able to provide those answers after analyzing the data, but some of the information most critical to the investigation was lost with the firefighters who died.
To protect the integrity of the report, the Team tried to keep in mind the difference between foresight and hindsight—that things often seem obvious once we know the end result, but not while they are unfolding. To make sense of their actions, one has to assume that the Granite Mountain crew's thinking was like that of anyone else with similar experience and background. We can only understand what happened by putting ourselves in their place, working with the facts as they knew then, and drawing our own conclusions.
Understanding this, the Team sought to provide the best framework possible for analyzing the unknowns and learning the lessons they provide. The result is the Yarnell Hill Serious Accident Investigation Report. Perhaps this approach is the only fair way to make sense of this tragedy. For most of us, it will serve to help us learn from their sacrifice and honor the memory of those who perished.
To read the full report, visit http://tinyurl.com/YarnellHillReport.