The 19 firefighters who died in the Yarnell Hill Fire this summer were “unnecessarily and unreasonably exposed to the deadly hazards of wildland firefighting” due to poor communications and the lack of an effective strategy the Arizona Division of Occupational Safety and Health has concluded after a comprehensive investigation.
As a result, ADOSH imposed $559,000 in fines and penalties on the Arizona State Forestry Division, most of which will go to the families of the dead firefighters.
Unlike an earlier internal investigation, the ADOSH probe concluded the commanders essentially failed to anticipate the movement of the fire, failed to keep track of the whereabouts of the Granite Mountain Hotshot crew and sent them into grave danger on a doomed effort to save an “indefensible” settlement.
The report revealed that at one point the communications got so chaotic that an air tanker put out a backfire the Granite Mountain crew had lit in an effort to create a firebreak that would keep the wildfire from reaching Yarnell.
The fire commanders never drew up a comprehensive or workable strategy for coping with the fire, delayed decisive action until it had grown out of control, failed to coordinate the activities of the crews and the air tankers, assigned the Granite Mountain crew a task with little chance of success and then lost track of the crew at the critical moment, the report concluded.
Lessons for Rim Country
Beyond the terrible details of the chaotic slide into tragedy, the unflinching report harbors a dire warning for forested communities like those scattered across Rim Country. The report concluded essentially that the failure of Yarnell and several other small communities to clear brush, create a buffer zone or adopt a firewise building code made it all but impossible for fire crews to save the homes from the onrushing flames. The fire consumed 127 homes, but an analysis showed it burned hardly any of the homes that had bothered to clear the brush well away.
In a conclusion that could affect future firefighting efforts, the report concluded the state should not have deployed the firefighters in a futile effort to the poorly prepared community. The crew was evidently trying to get into position to join the effort to keep the flames from reaching Yarnell when 2,000-degree flames trapped them in a canyon choked with brush. They had five minutes warning before the flames reached them and no chance of survival.
The deaths of the firefighters, the millions of dollars in ongoing annual costs for benefits paid to the families, the massive potential impact of lawsuits already filed and the increasingly “radical” behavior of fire in brush and forest that hasn’t burned in half a century will likely make fire managers much more reluctant to risk firefighters’ lives to save towns in the future.
The report concluded the state fire managers “failed to prioritize the safety of firefighters over the protection of non-defensible structures and property.”
Neither Gila County nor Payson have adopted firewise building codes. Such codes require flame resistant roofs, bar flammable overhanging porches and eaves, require clearing of brush around buildings and other measures designed to prevent a fire from spreading through a thickly forested town like Payson.
The findings give new urgency to sputtering local efforts to thin buffer zones around communities and embrace firewise building codes. Gila County has never seriously considered firewise building codes, but has approved a string of subdivisions just as indefensible as Yarnell. The county hasn’t even successfully pressed the U.S. Forest Service to provide alternative escape routes for communities like Beaver Valley. The Payson Fire Department pushed for the adoption of a firewise building code, but the effort died on a split vote of the Payson Building Advisory Board.
The deaths of six firefighters 23 years ago in the Dude Fire, just north of the Control Road in Rim Country foreshadowed the Yarnell tragedy. A 100-foot-tall wall of flame caught those firefighters when a towering superheated fire plume collapsed. They were also trying to protect a small, already evacuated subdivision built without a firewise building code in the middle of a thick, unthinned forest.
Compelling details revealed
The detailed ADOSH report provided compelling details of the unfolding catastrophe that ended with the deaths of the 19 firefighters. The investigators proved much more willing to assign blame than an earlier internal investigation — which essentially concluded that mistakes were made without assigning any blame.
The careful chronology in the report recaps the series of decisions that served to underestimate the fire and ultimately let it rage out of control with a change in the hot, dry, stormy weather patterns.
The lightning-strike-caused fire was first reported at 5 p.m. on June 28, but state fire managers decided to let it burn overnight, since they were preoccupied with the nearby Doce Fire and determined the fire was spreading slowly in an inaccessible area.
The fire had grown to eight remote acres by the morning of June 29. Fire managers decided to put a crew into place to try to turn a road into a firebreak and called for limited strikes from air tankers with fire retardant. After the air tankers made two drops, fire managers reported the fire size at about two acres early in the afternoon.
Thinking they had the fire contained on all four sides, the fire managers late in the afternoon released the air tankers to work other fires. Fire managers began reducing the scale of the attack despite 116-degree temperatures and the increasingly unstable weather reports and the threat of additional lightningcaused fire in the thick chaparral. An intensely fire-adapted system that normally burns every five or 10 years, the thick, highly flammable, drought-dry brush hadn’t burned in more than 40 years. In many of the canyons, the brush formed an impassable barrier 10 feet high.
At 4:30 in the afternoon, the fire jumped the single-track road fire managers hoped would contain its spread and grew again to six acres. The state fire managers then asked the Bureau of Land Management to take over control, but the BLM refused. The state managers then pleaded for additional firefighting aircraft at 5:42, but high winds made it too risky to move more aircraft into the area.
For the next two hours, the fire became more violent and unpredictable, moving toward Peeples Valley and Yarnell. The fire managers put out a series of calls for more fire crews, engines and air tankers, but remained consistently behind the fire’s escalating severity throughout the unfolding calamity. The investigative report made note of the increasingly scrambled communications and improvised strategy that marked the response to the fire as the weather and fire behavior became increasingly violent.
Granite Mountain Crew arrives
The Granite Mountain Hotshots, a wildlands firefighting team operated by the Prescott Fire Department, came onto the line the morning of June 30, after nearly a month in the field fighting other fires with little rest. After a hasty, relatively informal briefing at 7:30 a.m., the Granite Mountain crew took to the field, with instructions to clear a fire line along a Jeep road that they could connect to a more substantial line being cut by another hotshot crew with the assistance of bulldozers. The crew missed a more formal and comprehensive 9:30 briefing, which the ADOSH investigators blamed for the increasingly disjointed communications.
By now, the fire had grown to 500 acres and was spreading rapidly through the thick brush, posing a growing threat to Yarnell and other communities.
The Granite Mountain and the other hotshot crew moved to different sections of the proposed firebreak that they hoped would check the rush of the fire toward Yarnell. The investigators later faulted that decision, saying the separated crews couldn’t reasonably complete an adequate firebreak — especially while working separately.
To compound the difficulties, an air tanker at about 11:36 a.m. actually dropped a load of fire retardant on the backfire the Granite Mountain crew had started along the two-track Jeep road they hoped to connect to the line created by the bulldozers. The investigators cited that drop as glaring evidence of the lack of communications and a coordinated strategy, which ultimately rendered the efforts of the Granite Mountain Hotshots futile.
The fire crews shifted position and continued trying to create a firebreak to contain the spread of the fire, after posting lookouts to watch the fire front and warn the crews if a wind shift put them in danger.
By 2 that afternoon, an updated weather forecast predicted hot, dry winds of 35 to 45 miles an hour — which by 3:26 was updated to reflect the possibility of 50-mile-an-hour winds. At 3:30, the winds made an abrupt 90-degree shift in direction. Within 10 minutes, the fire reached the “trigger points” established to pull out the lookouts and dramatically increased the danger to the two hotshot crews still working to create a firebreak.
Rush to tragedy
The report notes that the head of the Granite Mountain crew “received the information relatively calmly.” The other hotshot crew in the area picked up the Granite Mountain lookout as he retreated and talked to the Granite Mountain crew on the radio. The leader of that crew said they were in presumably safe, already burned area and had a good view of the fire.
At 3:55, the fire was bearing down on Yarnell as several things happened at once. Central command and the Granite Mountain captain had a discussion about whether the team should stay put as the lookout reached the team’s trucks, which were then moved out of the path of the fire.
At 3:58, one of the key commanders left for Deer Valley after a long, grueling shift and turned over tactical control of the aircraft fighting the fire. The updates as the command shifted left some doubt as to the locations of the firefighters on the ground.
At 4 p.m., confusing and incomplete communications between overall commanders and pilots initially said the Granite Mountain crew was safe and “in the black,” but then indicated that the team was moving.
At 4:04, one of the Granite Mountain team members sent a family member a text message about the fire — one of the last communications received.
At 4:20, winds picked up as the fire continued to gain energy — moving now on a ravenous front at a speed of 16 miles an hour, as thunder and lightning crackled out of the rainless clouds.
At 4:22, the fire reached the second danger point for the two hotshot crews. The other hotshot crew was already leaving the area as fast as it could. The fire plume at this point was in the process of growing from 31,500 feet at 4:24 to an astonishing 38,700 feet by 4:33.
At 4:39, in the midst of a conversation between the fire commanders and the air tankers, a series of garbled, static-filled transmissions broke into the traffic. Fire commanders couldn’t understand the transmission at the time, but later realized that the Granite Mountain crew had moved out of the black and were calling for an air drop to stop the flames roaring down on them.
Between 4:40 and 4:42, the transmissions revealed clearly that the Granite Mountain team was trapped with flames bearing down on them as they rushed to burn out the brush around them and deploy their fire shelters. Later, investigators revealed that they were trapped in a brush-choked canyon a few hundred yards from the safety of a cleared zone around a ranch, with no chance of surviving the 2000-degree flames.
The report suggests that the fire commanders underestimated the fire from the start, given the tinder-dry conditions, the massive fuel loads on the ground and the lack of any cleared, defensible space around Yarnell or the other communities. Although the fire commanders and teams deployed were seasoned and well qualified, they never caught up to the behavior of the fire after waiting the first one or two days to mount an all-out assault.
Barely plausible plans to use the hotshot crews to hand-cut a long enough fire line to stop the fire were quickly overwhelmed when the hot, scalding winds picked up. When driven by a 10-mile-an-hour wind, a fire will move at about 2.4 miles an hour on 26-foot flame lengths — a speed the firefighters could outrun. But at 40 miles an hour, the fire will advance 12 miles an hour on 50-foot-long flames — a speed that makes escape impossible.
Moreover, decades of fuel buildup created “radical” fire behavior. The Bureau of Land Management had spent $169,000 clearing 375 acres in 2005 and 2011 and $27,500 to clear 40 acres in 2007.
By contrast, the 8,300-acre fire cost about $5.4 million to fight and destroyed millions of dollars worth of property. The Arizona Republic reported that the survivor benefits for the families of the dead firefighters would total $7 million up front and nearly $1 million annually indefinitely. Moreover, the town of Prescott has already said that it cannot pay the $24 million in lump-sum benefit payments and $52 million in total annual benefit payments it owes, since the firefighters were members of the Prescott Fire Department.
The report suggested that the Granite Mountain team never had a realistic chance of clearing an adequate fire line. A crew using hand tools can only clear about 436 feet of firebreak in an hour — and that firebreak probably wouldn’t stop a fire with flame lengths greater than 3.5 feet. By the time the fire reached the line they’d labored to create, the flame lengths were at least 40 feet.
However, because of the hastily assembled nature of the team commanding the fires, no one changed the plan as the circumstances shifted and no one fully appreciated the danger facing the crews on the ground, the investigators concluded. Normally for a serious fire, one person on the command staff does nothing but consider the danger that firefighters face given the overall plan. The command team functioned without a safety officer for crucial hours. Although one eventually joined the team, events by then were unraveling too fast.
The full reason behind the Granite Mountain crew’s decision to leave the relative safety of the burned area in an attempt to get to another safe zone at a ranch whose owners had done extensive brush clearing remain unclear.
The crew may have been trying to reach the safe zone to get back into the fight to save Yarnell. However, the report notes that they hadn’t previously scouted and timed the escape route from their position down to the ranch. Once they left a ridgeline and lost sight of the fire without a lookout posted, they struggled to make progress through the thick undergrowth. What might have looked like a quick move to a safer location instead became a death trap, the report concluded. The report also noted that exhaustion might have played a role, since the team had worked 28 days straight as of June 28.
• Fire behavior was extreme… The Yarnell Hill Fire continually exceeded the expectations of fire and incident managers, as well as the firefighters.
• Arizona State Forestry Division failed to implement their own extended attack guidelines and procedures.
• The incident management decision process failed to recognize that the available resources and chosen administrative strategy of full suppression and associated operational tactics could not succeed.
• ASFD failed to adequately update their risk assessment when the fire escaped initial attack leading to the failure of their strategies and tactics that resulted in a life-threatening event.