‘Complex conditions’ contributed to fire’s impact, say investigators
By Marcy Stamper
A newly released report on the Twisp River Fire of 2015 doesn’t isolate any single cause of the deadly entrapment, but concludes that several factors contributed to the tragedy.
Those include a firefighting culture that encourages risk-taking; confused and interrupted communications; inadequate training; and a lack of specific and timely weather forecasts.
“The Twisp River accident was not an individual or system failure but the effect of complex conditions,” investigators wrote in the report.
The U.S. Forest Service and the Washington Department of Natural Resources released a narrative of the August 2015 fire last week, along with an Operational and Organizational Learning Report that the team of experts hopes can prevent similar tragedies. Supporting documents include detailed accounts of weather, fire behavior, an analysis of protective gear, and multi-media components.
The narrative that reconstructs the chaotic events that took place over just three hours on Aug. 19 explains that the fire started in explosively dry conditions when 80 percent of the most-experienced fire crews were already deployed at other fires in the region. Against a backdrop of these already strained resources, there were 130 new starts in the week leading up to the Twisp River Fire, including the ignitions that became the Okanogan Complex Fire, the largest in state history.
A previous investigation determined that the Twisp River Fire started when tree branches rubbed against a powerline. The fire killed Forest Service firefighters Tom Zbyszewski, Andrew Zajac and Richard Wheeler and severely burned Daniel Lyon. They were entrapped when their engine went off the road as they were trying to escape in thick, blinding smoke about three hours after the fire began.
The investigators interviewed the firefighters and air crews who responded to the fire, as well as two dozen specialists in weather, fire behavior and organizational effectiveness. To protect privacy, they don’t identify anyone by name. The report does give their roles at the fire.
The authors describe the incident and their conclusions in bureaucratic and sometimes dense language. But it nonetheless contains stark details about the deadly incident and firefighting culture.
While firefighting contains inherent risks, the investigators described a culture that may encourage people to take excessive risks out of a desire to do a good job for their community for career advancement. “We need to examine how risk may be unintentionally incentivized in the current wildland fire system,” the report’s authors wrote.
Crews sometimes “engage the fire with the mindset that ‘we are already here; we might-as-well do something,’ with only secondary consideration of fire behavior, location, or resource benefit,” wrote the investigators.
“How do we help people learn how and when to disengage when they are otherwise rewarded over the course of a career for running in when others are running away?” the investigators asked.
Training for beginning firefighters is not rigorous enough, the investigators said. The surviving member of the Forest Service crew told the investigators that the training he received as a first-year firefighter had been inadequate. Minimum requirements include three online courses and a one-day field exercise. Relationships between weather and fire behavior are not well covered in the general training, according to the report.
Moreover, as a fire grows more complex, those with expertise are tapped for their supervisory skills, leaving inexperienced firefighters to take on leadership roles. “Engines were turned over to Assistant Captains; squads were led by less experienced Squad Bosses,” wrote the investigators.
Many in the Forest Service consider the position of a type 3 incident commander — the level often assigned to take charge of fires as they grow in complexity — to be the most challenging in wildland fire. The system asks these individuals “to make order out of chaos and to organize for the long-term while giving up as little ground as possible when the situation is at its most dynamic, developing, and uncertain,” the investigators wrote.
By contrast, the investigators found that training in use of fire shelters had been effective for the three bulldozer operators who deployed their shelters. “They said the videos ran through their minds over and over again, so deploying the shelters came naturally. They were ‘very impressed how well it [the training] stuck… very pleased and thankful,’” according to the narrative of the incident.
Gaps in communications
The report cites disordered and incomplete communications both because of multiple radio frequencies and the deafening conditions at the fire. Responsibility for dispatch in Okanogan County overlaps between two regional centers and, when oversight of the fire — including ordering ground and air resources — was switched during the fire, crews had to reset their radios.
“Air Attack said for the first 10 minutes he was on scene, he spent an inordinate amount of time trying to program new frequencies into the radio,” wrote the investigators. Some air crews were initially given incorrect frequencies, causing a significant delay.
The involvement of multiple agencies with different rules and areas of expertise also appeared to contribute to the confusion, said the authors.
The investigators also pointed to the need to use modern technology, including computers and cell phones, for spot weather forecasts and communication.
Even once helicopters were in the area, the smoke was often so thick that the pilots couldn’t see their targets. “Sometimes you could see a house and make a drop, but when you come back, that house has disappeared into the smoke,” said a helicopter pilot quoted in the learning report.
The report describes the almost-instantaneous wind shift, which caught some firefighters off-guard. Others were aware of the forecast but, when the wind shifted and the fire exploded, they were caught in a highly vulnerable situation on a winding, dead-end road, and unsure where to go for safety.
“They were confused about which direction to go because their predetermined escape route and safety zone took them in the direction of the hottest part of the fire,” wrote the investigators.
The investigators also found inconsistencies in the approach to emergency medical care for the burned firefighter. “It became clear to the Learning Review Team that although appropriate on-scene emergency medical care was provided for this patient in a timely manner, inconsistencies existed … [in] expediting patient transport to more advanced care vs. initial on-scene advanced care,” they wrote in the incident narrative.
Defending homes increases risk
“Structure protection further complicates any assessment of what is safe enough or aggressive enough,” wrote the investigators. These risks increase as people build homes in the wildland-urban interface, where they may be far from roads and resources but near forests and other potential sources of ignition.
These residents have a responsibility to create a fire-safe buffer around their homes, rather than expecting that firefighters will try to save them, wrote the investigators.
“Many people and communities who make their homes and livelihoods in inherently fire-prone areas have not committed to actions that would protect their values when a wildfire inevitably comes. We must work toward educating communities and taking action to develop more fire-resistant landscapes,” they wrote.
“Many questions after the tragedy at Twisp River revolve around what private owners expect in terms of structure protection. What should they expect? What can be reasonably provided, and who is best able to provide it? Although our fire managers are ingrained with the order to ‘fight fire aggressively, having provided for safety first,’ we still need to improve our understanding about the need to protect structures as compared to the risk of human life,” they wrote.
The learning review lists 10 recommendations for a safety action plan, including better communication between agencies, increased use of technology, consistent standards for driver training, and danger-zone assessment tools. They also encouraged wildland firefighters to adopt the system used in structure firefighting, including dedicated safety officers who map zones that shouldn’t be entered. There should also be a crew in reserve “waiting to save anyone who needs assistance,” the investigators said.
“It is likely that this is not the first but is hopefully the last time that a crew may have to negotiate a road in limited visibility. We have an opportunity to learn from their innovation. But more importantly this reinforces the need to not allow fire personnel to accept the risk of being on dead-end roads when there is a high potential for fire to cut off egress. We need to reinforce through training and protocols the need to recognize these situations, how to mitigate the risk, and then to know when to not engage,” they wrote.
The reports are available at www.wildfirelessons.net/viewdocument/twisp-river-fire-ent.