Report Details Errors That Led to The Death of A Young National Park Firefighter

Crews struggled to get Andy Palmer, 18, to a hospital after he was injured during a firefighting mop-up operation in July 2008. The ensuing investigation into his death pointed to a series of errors. U.S. Forest Service and family photos.

Fighting forest fires is one of the most dangerous occupations to partake in. And yet, many of those who fight these blazes are energized by the danger they encounter. You might say they get an adrenalin high battling the flames. And some firefighters die, more often than not because they were in the wrong place at the wrong time. That appears to have been the case when a young firefighter from Olympic National Park died on the fire lines in 2008.

Andrew "Andy" Palmer was just 18 when he joined the national park's firefighting crews in June 2008 just days after graduating from Port Townsend High School on the northern lip of the Washington State peninsula. A husky young man with an engaging smile, Andy and his four-person engine team were dispatched July 22, 2008, to help fight the Eagle Fire that was burning as part of the Iron Complex in northern California's Shasta-Trinity National Forest.

It was there, on the smoke-obscured slopes of the forest, that Andy bled to death.

A 115-page report released Tuesday paints a picture of an over-anxious crew on an ill-fated assignment, one befallen by mechanical breakdowns, seemingly ignored orders, firefighters ill-equipped to tend to catastrophic injuries, on-the-ground confusion, and smoky skies that delayed a helicopter evacuation of the young man who was on just his second firefighting assignment.

“This was a tragic accident and our hearts go out to the Palmer Family, his friends and his colleagues," National Park Service Director Jon Jarvis said. "Our intent in releasing this report is for all of us to learn from this incident in order to help prevent recurrences of this type of event in the future. This is how we will honor Andy, by remembering his commitment to self and colleagues. His passing should serve as a constant reminder to honor your fellow employees by watching out for their safety.”

Andy, a 6-foot-5, 240-pounder with a mechanical aptitude, was hired to be a firefighter by the national park four days after he graduated. Twelve days later he had completed his basic training, and on June 29 he was assigned to an engine crew. On July 22, roughly 12 hours after his team was summoned to duty, Andy and the others, anxious to reach a fire line, according to the investigation, were headed south to California. From that point on the assignment seemed overshadowed.

The Eagle Fire was the first out-of-park fire for Andy's crew. After four hours of driving, the team stopped about 1 a.m. at a motel in Kelso, Washington, to catch some sleep. Six hours later, according to the investigation, the crew was back on the road, but only briefly as the tailpipe of their new truck fell off. After picking up the tailpipe, they reported the problem and continued on south, only to encounter a "check engine" warning light.

While they were able to finally reach the fire's Incident Command Post near Junction City, California, about 6 p.m. the night of July 23, the crew's captain spent the next two days trying to get the truck, which was under warranty, fixed. He ended up picking up a loaner truck on the morning of July 25 and began to retrace his route to the fire camp. Andy and the remaining crew members, meanwhile, were sent to a fire line to cut potentially hazardous trees in advance of a fire mop-up crew. Their instructions included a specific direction not to cut trees over 24 inches in thickness at breast height as they weren't qualified to do so, the report noted.

It was shortly after 1:30 p.m. that day, when the crew captain was stopping for lunch, when a call for help came over the radio dispatch.

“Man Down Man Down. We need help. Medical emergency. Dozer pad. Broken leg. Bleeding. Drop Point 72 and dozer line. Call 911, we need help.”

According to the investigation, "A decision was made to fall a large Ponderosa pine (36.7” at the point of the cut). Downslope from the Ponderosa pine was a 54” DBH sugar pine that had an uphill lean and a large cat face (a fire scar) on the uphill side. When cut, the Ponderosa pine fell downslope toward the sugar pine. It was contact with the sugar pine, or vibration from the Ponderosa hitting the ground," that caused a 120-foot portion of the sugar pine to break off. As it slammed to the ground another section, approximately 8 feet long, broke off and fell upslope, hitting Andy and causing his injuries, noted the report.

Further radio communications reported that Andy had both a broken leg and fractured shoulder and that he was bleeding badly from his injuries. While a request quickly went out for a helicopter evacuation, one air ambulance said the conditions were too smoky for a rescue.

Complicating the rescue, according to the report, was that the extent of Andy's injuries were not clearly explained during the calls for help. A team of responding paramedics thought the injury was only a broken leg, and so it carried little more than a "vacuum splint and trauma bag." It wasn't until 55 minutes after Andy was injured that the responders visibly saw the profusely bleeding femoral injury.

In the heat of trying to save Andy, decisions over how best to get him to a hospital seemingly led to confusion between the Trinity Sheriff's Office and a U.S. Forest Service safety officer, as a U.S. Coast Guard helicopter was summoned and then told to "stand down" because a U.S. Forest Service helicopter seemed closer. The need to hoist Andy into a helicopter led to the eventual decision to clear a small landing zone so the USCG helicopter could ferry him to help; the Forest Service whirlybird couldn't respond quickly enough because it didn't have hoisting ability, the report noted.

Confusion over how best to get Andy to a hospital was then interrupted by concerns over whether he needed more on-site treatment for his injuries rather than trying to rush him off the mountain. It was during this debate between two paramedics that a decision was made to clear a landing zone -- a process that took "about 20 minutes" -- where they were so Andy could be hoisted into a helicopter. Two hours and 47 minutes after he was injured, Andy was finally hoisted into a USCG helicopter. Thirty-nine minutes later he was pronounced dead before ever reaching a hospital.

The report identified a series of errors that seemed to cascade and compound matters in leading to Andy's death:

* Andy's team "was given a line assignment without adequate supervision for the assigned task," and, with the captain away trying to get their truck repaired, the second in command "failed to exercise proper supervisory control by allowing" the team to cut down trees above their level of certification.

* "Excessive motivation for (the crew) to obtain a line assignment led to a series of inadequate communications and assumptions which subsequently led to a mismatch between resource request and resource assignment."

* The Ponderosa pine was "felled by an unqualified sawyer" and "escape routes/safety zones were not effectively utilized by" Andy.

* "There was insufficient pre-planning to integrate incident personnel and resources into the local emergency management system, taking into account local factors, including environmental conditions, to effectively manage a serious injury and the subsequent medical evacuation."

* "Inadequate leadership, communication, and risk management resulted in a lack of clarity in communicating the severity of the injury, resource availability, and a failure to evaluate the most appropriate method of evacuation relative to risk exposure, resources required, and timeliness."

* "The National Park Service fleet management procedures for quality control are inadequate to ensure mission ready condition of new wildland fire engines and to appropriately handle maintenance and repair issues."

Beyond those points, the report pointed to a lack of command at the scene of the accident, a failure to clearly communicate the extent of Andy's injuries, and a miscalculation in how best to get Andy to a hospital.

While there was a law enforcement investigation of the accident, the assistant U.S. Attorney declined to pursue charges. Other than the captain of Andy's crew, no other crew members agreed to be interviewed by the interagency Serious Accident Investigation Team, according to the National Park Service.

You can find the full investigative report, and its supporting documentation, at this site.

Comments

12 days of training ??? That's it ?? I was a volunteer firefighter in Kentucky and we had to have 150 hours of classroom and hands-on training just to even ride the truck out on runs plus oral, written and practical tests... Plus an over-eager/undertrained crew is a recipe for disaster, guess they didn't bother with Incident Command System either. I hope this agency will consider more training for new employees and come up with some sort of pre-incident plan for rescue or what some departments call "Rapid Intervention" to get people out of trouble on scene. For their screw-ups they probably promoted the supervisors to GS-15...

Firefighting crews get hazardous pay for an entire workday provided they make it to the fireline by midnight. Follow the money. It often results in "...Excessive motivation for (the crew) to obtain a line assignment..."

The fire service is unfortunately plagued by several factors that will continue to result in looking at the obvious preventable events during post incident reviews. First and foremost is the current lack of hubris amongst most managers, they have glided to top positions based upon networking and lack the common gut check of a lowly military sergeant with years of experience and a desire to complete the current mission and future missions without fanfare and hyperbole. Secondly, and this is both good and bad, every fire fighter worth his salt would like to be in the middle of the biggest event, we are all chomping at the bit to be on running the line (structural fire fighting) or on the line (wildland fire fighting) thus many of the youngest fire fighter get tunnel vision and lack situational awareness. Unfortunately the lack of experience combined with the lack of experience but a great deal of networking have begun to work in concert to affect operations nation wide.

As a former Battalion fire chief I tried to add one paramedic to each crew dispatched to an incident, the obvious reason was they have the skill, and the vocabulary to assess a medical emergency, apply the appropriate field treatment, and request help in a manner that identifies the problem and resources needed to successfully manage the outcome. Unfortunately my deployment of personnel was completely denied by a Division Chief whose experience was limited to budgets, and networking meetings with pre-hospital clinicians. The short sighted excuse was cost; however all cost associated with deployment of resources is bourn by the park service, additionally failure to assess potential problems and apply now traditional methods to manage them will continue to cripple effective efforts of fire fighters who are faced with real problems in real situations and seek solutions from networking managers.

In essence the problem is obviously the outcome; but more specifically the inability to assess factors that are preventable, and the lack of EXPERIENCED knowledgeable stewards of young apprentice fire fighters instead operational management has defaulted to the leader with a great business card collection and limited practical experience. Many of the current fire service managers lead autocratically and will judge situations utilizing questionable or unreliable information either through ignorance or inability to form tactical decisions that are well heeled through years of experience; instead the world of the fire fighter has become increasingly the prevue of the electronic book chief with little to any practical fire experience.

The solution is greater use of difficult tactical scenarios in promotional exams, greater reliance on real world training, and greater reliance on professional apprenticeships to ensure acquisition of fundamental skills.

Speaking as a former FF/EMT - in a suburban, not rural, environment - I have to echo the amazement at "12 days of training". As volunteers we had to meet the same physical exam and training as our career firefighters, to a national standard. We had months of academy and then rookie-hood to earn our way on the line.

I've been out of fire service for over 20 years now, and can't believe that things would have shifted so much. Actually, I don't think they have. I just think that in some situations some folks feel "it's trees, not cities" and shove folks out there to fight and die.

I really admire the transparency of Director Jarvis in publishing this report, warts and all, for folks to learn from.

I was on this fire as a Fireline Supervisor in a neighboring Division when this occured and talked with numerous fireline personnel directly involved with this incident. The report is more accurate than most when there is a fatality on a Forest Service fire, however, I think a bit of clarification and comments are needed.

First, firefighting has been declared by the courts as being "inherently dangerous." Second, this accident resulting in a fatality was clearly avoidable. Both in the incident itself and the unbelievably bogus medivac operation.

"The second in command 'failed to exercise proper supervisory control by allowing' the team to cut down trees above their level of certification." The second in command was the one cutting the trees.

They "were sent to a fire line to cut potentially hazardous trees in advance of a fire mop-up crew." Bullshit! The 72 Hour report states that their mission and activity were: "Mitigating Hazard trees during mopup" and "Felling a tree to secure the line." The "factual" report stated that: "The assignment was to mitigate hazard trees along the fire line." One again - BULLSHIT! THE LINE WAS ALREADY SECURE and had been for days. This was one of the coldest Divisions on the fire. You mitigate hazard trees before you go in an area to mop up, not afterwards. This is merely to cover up their sport falling activities.

If you ask any fireline or Crew supervisor how many GREEN trees WITHOUT any fire and WITHOUT any cat-faces they have felled "to secure a fireline for mop up," and their answers will unequivocally all be NONE.

"The resulting contact, or vibration from the ponderosa hitting the ground, caused a portion of the sugar pine, ... , to break off and fall upslope." It was clearly contact from the felled green tree that caused the dead sugar pine to snap off - vibration had nothing to do with it.

They were attempting to fall a smaller tree into a larger one to knock it over, something that never works and just isn't supposed to be done.

Flat out - these guys were "sport falling" - just cutting trees to cut trees. This was verified by many fireline personnel on that Division. Division B Firefighters and Fallers stated that they witnessed about 16 trees of varying diameters with some still hung up in trees that they guys cut down, even though the "factual" report mentions "an undetermined number of trees." They know how many were cut, they just won't say.

"Their instructions included a specific direction not to cut trees over 24 inches in thickness at breast height as they weren't qualified to do so, the report noted." There was a signicant lack of leadership and oversight on this Division to allow this to happen throughout that entire shift.

"FC2 and FC3 are the only surviving witnesses to the accident and they have not granted interviews to the Serious Accident Investigation Team." These two guys were doing something unsafe and wrong and they know it, and unfortunately they are too cowardly to come forward and admit the truth.

Do you see all those firefighters hauling the injured down the fireline? Look at the map and see how close to the road this occured. A stokes litter on a longline and these firefighters hauling him down the hill for ground transport could have been accomplished in about an hour. Instead, it took three hours - THREE HOURS!

There were even more medivacs in the days that followed and each one of them was ridiculously slow in the range of several hours. At least one SAFENET was filed on this very thing.

It is most unfortunate that this occured. I feel terrible for this young man's family. Once again, this was totally avoidable.

As a past fire chief, wildland engine striketeam leader with dozens of deployments, and a certified wildland firefighting instructor with 35 years of firefighting, I am beyond dumbfounded as to how the National Park Service could allow this to happen. And then in a region of the United States that has had more than its share of wildland fatalities, this continues to happen. While I don't want to discredit the crew, it seems to me that this was a case of the engine captain leaving his crew in strange territory, without a qualified "engine boss" and it looks like the crew quite frankly was freelancing......where was the "falling boss" that should have been assigned to the crew? Obviously the crew could not follow directions on the size of tree to cut and they had to have known that they were not class "C" fallers. Who at fire camp sent them out un-supervised? Why was the engine captain running arround trying to get the engine fixed, does the USFS not have the resources available to send out another truck or a service contract to get equipment repaired, hogwash!!! I have been to dozens of fires in the NW and have yet to see a fire camp without a mechanic. And for that matter, why did the crew continue to operate an emergency vehice with a check engine light on in the first place. Aparently the captain was distracted with vehicle problems to the point that he lost sight of his duty and responsibility to lead and command his crew. This in my eyes would be very unacceptable behavour. And then we get to the incident itself, I can not fathom how the 3 or 4 of them could overlook the dangers of what they were doing and continue to get in way over their training level. Where was the LCES in the process? It looks to me that the EMS response was just as flawed as the crew's action. The medics knew they were responding to severe trama with bleeding in the wilderness so why all the confusion, order the med-e-vac and plan for the worst. Sounds to me that there was a major lack of command and control and as a result, a young firefighter had to die. While I also commend director Jarvis for releasing this report, I would hope he and his administration would hold accountable the crew, the overhead team at the incident, and the district ranger from the home unit. They all need some serious re-training and someone to hold them accountable at a very minimum.

first and foremst my heart goes out to andys family! this is a direct relation to a lack of training all the way around. as a timber faller that has contracted on fires in r5 for the last six years. most not all sawyers are not timber fallers and have no business falling big and hazordous trees. i have seen too many times the big tree syndrome( wanting to see and hear big trees go down) as timber fallers most of us must buck behind a faller for years before we are turned loose on small trees. then after that we must prove that we can handle big trees before we are allowed to fall them by ourselves. any time myself or anybody i work with always try to show these younger sawyers what, why and how we do the things we do to help them avoid accidents like this. we're there to help not just in falling but in education too. it's tough to monday moring quarterback somthing like this unless you are standing at the stump. you don't know what that person saw or didn't see. there are just too many varibles and if you havn't seen most of them you're putting yourself and the people around you in jepordy. these crews need more training not from a book or sombody that has never cut logs for a living or spent years in the woods handling a saw. it needs to come from sombody that has seen what might happen if you don't know. cause most of these kids aren't getting the experience they need.

Thousands of wildland firefighters have successfully fought thousands of fires with the standard 40 hr training. Training does not just end after Basic Firefighter school. Every crew I have been on has continued with training as part of their daily routine after initial rookie training. The issue here is leadership and the imperfect wildland firefighting system we live with today. Also this fire was the responsibility of the US Forest Service, not the National Park Service. Have not read the full report yet but this summary leaves many questions. At least the National Park Service had the institutional fortitude to post the report online, unlike the US Forest Service.

totaly spot on.

I must add my condolences to the family as well. I am a former EMT and Army medic but have been out of it for many years so am unfamiliar with current practices. I do feel however that this fatality was avoidable.

Any injury involving the femoral artery requires instant action due to possibility of bleed out. If pressure bandaging or pressure point application does not stop bleeding use of a tourniquet seems called for. Due to time involved this may have resulted in permanent damage to the limb but at least it would have left this young man with enough blood in his body to survive.

I would think training would include at least basic first aid which would call for tourniquet in cases of uncontrolled bleeding and of course treatment for shock, which can also kill.

While I wont second guess what caused the accident it does seem with basic injury treatment the fatality could have been avoided, if that is, death was caused by loss of blood and/or shock.

My heart goes out to Andy's family & friends. What a waste.