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The last 25 postings on the Lessons Learned Center Web site are listed below:
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Bias for Action
(184KB pdf posted 9/2/2010)
Morton Incident FLA
(242KB pdf posted 9/1/2010)
The following information is a preliminary summary of a vehicle accident that occurred on the
“Morton Fire” in which two San Bernardino County Paid Call Firefighters suffered minor injuries and
a Water Tender sustained substantial damage.
Lessons Learned Eagle Trail IHC Saw Accident
(64KB pdf posted 8/31/2010)
Sawyer assessed a tree that had fallen into two
other trees and was suspended with a root wad,
and hung in two other trees. The sawyer attempted
to cripple the tree nearest to the tree that was root
sprung. Sawyer then attempted to face the tree
with a bird beak, hoping to drop the bole to the
ground. The bird’s beak was unsuccessful so, the
sawyer attempted to picket cut the tree. When the
sawyer cut the tree, the bole swung up in the air
from the tree that the sawyer did not fully cripple.
The tree pivoted towards the sawyer, striking the
sawyer in the face, cutting the sawyers nose and
bruising the sawyers shoulder and clavicle.
Seatbelts and Driving Safety Alert
(24KB pdf posted 8/31/2010)
Recently, a BLM driver experienced a vehicle rollover accident and died from the injuries he sustained. He was not wearing a seatbelt at the time of the incident and was ejected from the vehicle. In the past few years, BLM has experienced multiple vehicle accidents in which occupants were not wearing seatbelts.
Lessons Learned Stanislaus NF Vehicle Off Hwy
(106KB pdf posted 8/31/2010)
The employee left the Groveland Ranger District office at approximately 1030 to attend a lecture in Yosemite National Park. He recalled being fatigued all day. After the lecture he had lunch with the presenter and then travelled back to the Groveland District Office, westbound via Highway 120, at approximately 1400. He remembers driving defensively amongst the heavy tourist traffic, and actively rolling the windows up and down and cycling the air conditioner on and off for comfort, but did not notice that he was fading into sleep.
Cow Creek Fire Emergency Evacuation Mitigations
( pdf posted 8/31/2010)
Lessons Learned on Firefighter Emergency Evacuation in Remote Backcountry
Our wildland fire assignments often occur in remote terrain where emergency firefighter extraction can be highly challenging. The Rocky Mountain Team B Incident Management Team recently comprised this insightful After Action Review report on Emergency Evacuation Lessons Learned. These significant insights were gleaned from the team’s July 2010 assignment on the Cow Creek Fire, located in remote backcountry inside Colorado’s Rocky Mountain National Park. It is hoped that this AAR will help improve Standard Operating Guidelines as well as assist other IMTs in addressing the recently issued NWCG Guidance for Dutch Creek Mitigation Measures. These mitigation measures surround corrective actions that wildland fire agencies are undertaking in response to firefighter Andy Palmer’s death following a tree felling accident on the 2008 Iron Complex, Shasta-Trinity National Forest.
Daven Place 72 hr Report
(27KB pdf posted 8/30/2010)
Lessons Learned Fisheries
(64KB pdf posted 8/30/2010)
Forest Service Fisheries Biologists have been conducting fish counting snorkel surveys in rivers on the Shasta-Trinity since 1978 with partner agencies and volunteers. Sections of rivers of varying length and technical difficulty are surveyed by teams of at least two divers. Each section or “reach” is flagged at one team’s put-in to identify the take-out for the team working upstream. Put-ins and take-outs can involve hikes of up to 3 miles and reaches can be from 1.6 to 5.8 river miles in length. The work is physically demanding, presents in-water hazards and is in remote areas often with poor radio communication. Divers are often exhausted before completing the reach and hike out. Access and exit points can be limited due to steep terrain along the river’s edge. Some survey reaches take two days and an overnight in wilderness.
Lessons Learned with ATVs
(36KB pdf posted 8/30/2010)
A trails crew seasonal was in the process of maintaining a portion of a trail. As he was riding to his work
area, his ATV clipped the uphill side of the trail edge on a narrow portion of the trail. This tipped the ATV
and it began to slowly roll over. The rider jumped off to the downhill side and attempted to stop the rolling
motion. He quickly realized he could not stop the ATV and jumped away to the front side to avoid getting
hit or pinned. The ATV gained momentum and continued rolling downhill approximately 60 feet before it
came to rest upright on a ledge. The ATV, a six year old Honda Foreman 500, it was seriously damaged
and will not be repaired. No persons were hurt or injury.
NIMO Briefing Paper 8-30-09
(45KB pdf posted 8/30/2010)
The NIMO program is used on and off incidents to help wildland fire agencies address issues and improve current and future fire management. As seven person teams of command and general staff positions, they can be dispatched as a short team to manage incidents that need a more customized approach such as long-term fires in remote locations, which can reduce cost and provide consistency that allows for an additional level of safety; coordination support at regional or national Multi-Agency Coordinating (MAC) group levels; specialized incidents within an incident such as an aviation accident; or as an advisory group to assist a Type 2 team in handling complex situations for a short period time so transitions don’t have to occur during critical periods on an incident. Their small size makes them agile while their fulltime status makes them available at any time.
CISM Brochure
(96KB pdf posted 8/20/2010)
Sometimes Incident Personnel experience stress reactions because of a particularly traumatic event, or because of the cumulative effect of stressful events. Critical Incident Stress Managment (CISM) services are crisis intervention techniques that help participants reduce stress levels and experience less stress symptoms. These CISM related interviews will provide you with information on CISM Peer Teams and how they help to establish trust and increase effectiveness.
CISM Guidelines for Fire Management
(25KB pdf posted 8/20/2010)
Sometimes Incident Personnel experience stress reactions because of a particularly traumatic event, or because of the cumulative effect of stressful events. Critical Incident Stress Managment (CISM) services are crisis intervention techniques that help participants reduce stress levels and experience less stress symptoms. These CISM related interviews will provide you with information on CISM Peer Teams and how they help to establish trust and increase effectiveness.
IMT-HRSP Roles and Support for CISM
(56KB pdf posted 8/20/2010)
Sometimes Incident Personnel experience stress reactions because of a particularly traumatic event, or because of the cumulative effect of stressful events. Critical Incident Stress Managment (CISM) services are crisis intervention techniques that help participants reduce stress levels and experience less stress symptoms. These CISM related interviews will provide you with information on CISM Peer Teams and how they help to establish trust and increase effectiveness.
Deer Park Incident Map
(332KB pdf posted 8/19/2010)
Organizational Learning APA & FLA Guides
(2MB pdf posted 8/19/2010)
Deer Park Incident FLA
(1MB pdf posted 8/19/2010)
The Deer Park Wildfire was ignited by lightning in remote and rugged terrain on the Sawtooth National Forest, located in central Idaho, on August 6, 2010. Smokejumpers were ordered to staff the fire, which due to dry conditions and high winds quickly grew to several hundred acres. Smokejumpers set up a Type 3 Incident Management Team and ordered additional resources, including 5 Hotshot and 3 Type 2 IA crews.
Overcoming dysfunctional momentum: Organizational safety as a social achievement
(140KB pdf posted 8/18/2010)
Research on organizational safety and reliability largely has emphasized
system-level structures and processes neglecting the more
micro-level, social processes necessary to enact organizational
safety. In this qualitative study we remedy this gap by exploring these
processes in the context of wildland fire management. In particular,
using interview data gathered from 28 individuals involved in
wildland firefighting, we explore the validity of the idea that a
deterrent to organizational safety is an inability to redirect ongoing
actions once they are underway. The findings suggest four major
themes. First, individuals and groups redirect ongoing action as a
result of re-evaluating that action. Second, noticing early warning
signs, while necessary, is not sufficient to drive change. Third, two
social processes – giving voice to concerns and actively seeking
alternative perspectives – appear to be key drivers of re-evaluation.
Fourth, the process of redirecting action is moderated by two social
factors: institutional pressures and self-interest.We discuss the implications of these patterns for organization theory and for future
research.
Scratchline 27
(2MB pdf posted 8/16/2010)
Wildfire Academy Lessons Learned - The LLC staff recently interviewed seven fire training academy coordinators around the US regarding their notable successes, difficult challenges, effective safety practices, training recommendations and unresolved issues in the implementation of fire training academies.
Daven Place Fire 24-Hr Report
(11KB pdf posted 8/16/2010)
One firefighter with 2nd degree burns to hand, Two firefighters treated for smoke inhalation, one USFWS Type 5 engine with minor damage, one Franklin Co FD #3 Type 6 engine with extensive fire damage and one USFWS command vehicle with fire damage.
Lessons Learned Center 2002 to 2010 Presentation
( pdf posted 8/8/2010)
David Christenson gave this 20 minute presentation at the Human Dimensions in Wildland Fire Conference in April, 2010. The International Association of Wildland Firefighters brought people to San Antonio, Texas from all over the world to learn more about the science of firefighters fighting fire. We were able to give them a little history, a quick update and a few things about future directions of the LLC.
Sand 2 Incident, Firefighter Heat Injury (Blisters)
( pdf posted 8/7/2010)
"On July 18, 2010, a Firefighter was assigned to the Sand 2 Fire as a member of an U.S. Forest Service Hotshot Crew. The Firefighter was deployed under the direct supervision of a Captain with a Superintendent in overall command of the Hotshot crew. While constructing direct fireline, the Firefighter was operating a chainsaw cutting on a fallen log and was standing in hot ash while performing this task. The Firefighter began to feel heat through his boots and would from time to time back off to allow some cooling to take place and then step back into the ash to work again."
This Day in History - Helicopter Longline Accident
( pdf posted 8/4/2010)
U.S. Forest Service Fire Operations Risk Management Hazard Tree Risks and Mitigations
( pdf posted 8/3/2010)
"Many areas in of our nation’s forests are experiencing declining forest health conditions causing extreme hazard tree dangers. Broken tops, widow-makers, and root rot in many tree species are contributing to elevated hazard levels. Beetle infestations, wind events and abundant moisture have led to the creation of abnormally high safety hazards which are difficult to mitigate. This Hazard Tree safety advisory is designed to raise awareness among firefighters and all field going employees of the increasing risks from falling tree hazards in forested lands across the United States."
Constantia Fire Burn Injury Non-Serious Accident Investigation Report
(221KB pdf posted 7/31/2010)
"At approximately 12:22 on 7/25/2010 a crewmember of the Diamond Mountain Hotshots was injured while working on the Constantia Incident, five miles south of Doyle California. The fire fighter was working on a tree torching near the line on Division T, fell and received minor burns to the left hand due to not wearing gloves."
Plug Hat Fire, Damage to a Government Vehicle - Report
(165KB pdf posted 7/31/2010)
"On Monday, June 6, 2010 at approximately 1745 hrs, an Initial Attack (IA) Squad Vehicle sustained burn damage. The IA vehicle was on site to support wildland fire suppression operations while assigned to the Plug Hat fire, located on lands managed by the BLM White River Field Office in Northwest Colorado. The vehicle was parked in the black while the crew was engaged in suppression operations."
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