Sequoia & Kings Canyon National Parks62 ページ中 11 ページ
Grant West Case Study
Dan Holmes NPS
On the morning of Saturday October 2, 2004, staff from Sequoia & Kings Canyon National Park began a prescribed burn in the Grant Grove area. The Grant West prescribed burn was part of larger effort to reduce risks from wildfire, protect resources and reintroduce fire as a critical part of the landscape.
During the seemingly common task of sizing up a burning snag and relocating a hose lay, Daniel Holmes, a member of the Arrowhead Hotshots, was struck and killed by a burning top from a tree. Dan was 26 years old.
Studying the events of the accident and the stories of grief, resilience and recovery allows us to gain wisdom from his sacrifice.
Ground Rules
As you work through the case study, try to place yourself in the shoes of the Grant West prescribed fire personnel from 2004. Avoid the temptation to allow knowledge of the outcome to shape conversations. Suspend hindsight bias, ask thoughtful questions and encourage honest dialogue. Consider what you can take away from this tragic event to change how you approach similar situations in the future.
Background
Grant West Case Study Background
Background
Sequoia and Kings Canyon National Parks (SEKI) have a long history of fire management. Prescribed fire is one tool in a comprehensive approach to restore and maintain historic fire regimes. The use of prescribed fire provides the combined benefit of ecosystem balance while reducing the severity of unwanted wildfires. Prescribed fire reduces high fuel loading under controlled conditions, whereas wildfires may occur during extreme conditions, cause widespread damage, and threaten visitor safety and private property. The long history of SEKI’s prescribed fire program has demonstrated the value of focused fire applications and the need to continue fuels reduction efforts.
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Duration:5 minutes, 7 seconds
Provides background information for the virtual Grant West Staff Ride. This is the first video participants will watch.
Description and Discussion Questions
On the morning of October 2, personnel from SEKI and elsewhere gathered at Grant Grove in readiness for the burn. In addition to the normal prescribed fire overhead positions, the Burn Boss and Ignition Specialist each had a trainee. Briefing for overhead personnel was held at 0800. A general briefing was held at 0900.
Leadership Elements: Human Factors, Preparedness, Normalization of Risk
Location: Grant Grove Engine Bay
Date: October 2, 2004
Time: 0900
You are a Squad Boss on a 20-person hand crew from the local area. It is October 2, 2004, at 0900. You and your crew are attending the briefing for the Grant West prescribed burn. As expected, during the briefing it’s confirmed that the Crew Superintendent will be pulled off as the Division A Holding Boss and the Crew Foreman (Captain) will be used as the Ignition Specialist (now referred to as the Firing Boss). You are put in charge as Crew Boss and will run the rest of the crew (yourself + 17).
You were expecting this and were not caught off guard. Take 1-2 minutes to prepare a briefing on the assignment to your group.
- What preparations would have you made in anticipation of the assignment?
- What concerns do you have?
- Is there anything specific you would reiterate or brief your crew on in addition to what was covered in the main briefing?
- Is there anything that concerned you about the IAP?
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Duration:7 minutes, 9 seconds
Stand 1 for the virtual Grant West Staff Ride.
Description and Discussion Questions
You are a saw team member with the 20-person local hand crew that has been assigned to assess the snag work along the trail. It is your first year on the crew. You have been on two previous prescribed burns at SEKI, including the one last week. You are familiar with the area.
Leadership Elements: Normalization of Risk, Hazard Assessment, Situation Awareness
Location: Grant Grove Horse Corral Parking Area
Date: October 2, 2004
Time: Approximately 1000
- What hazards can you identify?
- What burn preparation would you like to see completed?
- What is your agency’s current snag protocol?
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Duration:3 minutes, 28 seconds
Stand 2 for virtual Grant West Staff Ride.
Description and Discussion Questions
At 1042, all fireline personnel were in place and the Burn Boss and Burn Boss trainee determined that operations would begin with a test burn near the eastern edge of the burn unit. This test burn would allow them to evaluate burning conditions and smoke dispersion. The test burn was larger than normal so that sufficient smoke would be generated to accurately evaluate dispersion. It showed the dispersion was to the northeast, a very favorable condition. Winds were generally from the southwest and light and variable.
Leadership Elements: Hazard Assessment, Situation Awareness, Developing a Plan of Action, Human Factors
Location: Go/No Go Checklist Site
Date: October 2, 2004
Time: Approximately 1230
You are the Division A Holding Boss (who was pulled from the crew). While waiting for the Burn Boss and Ignition Specialist to arrive for a go/no go checklist chat you notice that the top of a snag on the handline has caught fire.
Take 1-2 minutes to prepare a briefing to your group on what options are available for dealing with the snag.
- What are your options?
- With whom, if anybody, would you discuss this with?
- What decisions would you make and why? Explain your rationale.
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Duration:1 minute, 30 seconds
Stand 3 for virtual Grant West Staff Ride.
Description and Discussion Questions
The Division A Holding Boss was aware of the fire in the top of the snag and considered it a spot fire risk which needed to be felled. A Class C falling team from the Arrowhead Interagency Hotshot Crew was called to evaluate the burning snag. After sizing up of the snag, the decision was made to fall it in the direction of the lean which was across the fireline. Before that could occur the hoselay needed to be broken down and moved.
Leadership Elements: Continued Situation Awareness, Human Factors, Command Presence,Decision Making, Effective Communication Under Stress
Location: Fatality Tree
Date: October 2, 2004
Time: 1246
You are the Crew Boss of the local hand crew. One of your crewmembers was just struck on the head by the top of burning snag. The accident was witnessed by yourself and 15 other members of your crew.
Take 1-2 minutes to come up with a plan and rapidly brief your crew.
- What are your immediate concerns?
- What decisions would you make and what actions do you take?
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Duration:5 minutes, 17 seconds
Stand 4a for virtual Grant West Staff Ride.
Description
Holmes’ spine was stabilized by hand and efforts were made to keep his airway open. Fearing further injury by moving him without a backboard, the EMT’s treated the firefighter where he fell, directly under the burning snag. A dedicated lookout was posted. Hoses were deployed to cool hot surface areas, reduce smoke, and extinguish falling embers.
At 1248 an ambulance and park medic were requested by the Burn Boss Trainee. At the same time, Arrowhead personnel were sent to retrieve additional medical equipment. Shortly thereafter at 1251, a medical helicopter was requested for transport to a trauma center. Upon arrival of a Ranger/EMT and the Grant Grove ambulance, Holmes was placed and immobilized on a backboard and moved from under the snag to a safer area. He was then carried to the road by firefighters and placed in the ambulance at 1313.
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Duration:2 minutes, 34 seconds
Stand 4b for virtual Grant West Staff Ride.
Description and Discussion Questions
Leadership Elements: Human Factors, Decision Making, Effective Communication Under Stress** **Location: McGee Overlook
Date: October 2, 2004
Time: 1358
You are the Crew Boss of the local hand crew. Your crewmember who was struck on the head by the top of the burning snag has just been pronounced dead. The rest of your crew has been released from the burn and is back at their station.
- How can you be prepared for a worst-case scenario?
- What do you need to start thinking about and what is your next immediate step?
- How will you go about notifying your crew who are still unaware of the crewmember fatality? (Note: this is an impactful moment and you really only have one chance to do this.)
- How would this situation differ if the crew was out on assignment away from their home unit?
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Duration:4 minutes, 10 seconds
Stand 5 for virtual Grant West Staff Ride.
Description and Discussion Questions
Leadership Elements: Effective Communication Under Stress, Command Presence and Control, Empathy, Developing a Plan of Action, Taking Care of Your People
Location: Swale Work Center
Date: October 2, 2004
Time: Mid to late afternoon
You are the Crew Boss of the local hand crew. You arrived at your duty station and gathered up your crew. You notify them that the crewmember who was struck on the head by the top of the burning snag has been pronounced deceased.
- How do you start mapping out and planning for the next 24 hours? 48 hours? The next few days and the next week?
- What are your most critical concerns currently and what actions can you take?
- Do you release your crew or keep them together? Does the crew go available for assignments again and if so, when?
- How do you manage communicating this tragedy? What do notifications look like for the media versus the next of kin? (Consider the following quote: “You only get one chance to do this right”.)
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Duration:6 minutes, 51 seconds
Stand 6 for virtual Grant West Staff Ride.
Incident Resources
Supplemental materials and mental health resources for the Grant West Incident - Daniel Holmes fatality.
Designated Agency Safety and Health Official (DASHO), Department of the Interior Memo
Transmittal of the Daniel Holmes Fatality Investigation Report, Management Review and Corrective Action Plan
Associate Director, Visitor and Resource Protection /s/ Karen Taylor-Goodrich Memo
Fatality Investigation Report, Management Review and Corrective Action Plan for the Daniel Holmes Accident
National Park Service Releases Fatality Investigation Report
Management Review Corrective Action Plan for the Daniel Holmes Accident
Board of Review Management Review and Corrective Action Plan
Cover Memorandum for Transmittal of Management Review and Corrective Action Plan
Final Report—Holmes Accident Investigation
Final Report of the Serious Accident Investigation Team (SAIT) and Board of Review (BOR) regarding Daniel Holmes Fatality
Questions & Answers (Q&A) Related to the Holmes Accident Investigation
Questions and Answers in support of the Final Report regarding the Daniel Holmes fatality and investigation
72 Hour Report—Grant West Prescribed Fire (Sequoia and Kings Canyon National Parks)
72 Hour Report relating to the fatality of Arrowhead Hotshot, Daniel Holmes. Report date—October 3, 2004
24 Hour Report—Grant West Prescribed Fire (Sequoia and Kings Canyon National Parks)
24 Hour Report relating to the fatality of Arrowhead Hotshot, Daniel Holmes. Report date—October 5, 2004
988 Suicide and Crisis Lifeline
Free and confidential support for anyone that is in distress; you do not need to be experiencing suicidal ideation to utilize the service.
- Available 24/7
- Call or text 988
- For TTY users: Use your preferred relay service or dial 711 then 988
- Online chat available at 988lifeline.org/chat
Veterans Crisis Line
If you are a Veteran in need of support, please connect with the Veterans Crisis Line
- Call 988, then press 1
- Text the Veterans Crisis Line at 83825
- Chat online by visiting veteranscrisisline.net/get-help-now-chat
Employee Assistance Program (EAP; Espyr/Acentra Health)
Services are confidential and provide free sessions with a licensed mental health provider.
- Call 800-869-0276 to speak with a live counselor 24/7, 7 days a week
- Visit EAP SharePoint (National Park Service internal link)
Responder 911 - National Park Service only
This service provides access to a trained mental health professional who specializes in working with law enforcement and first responder personnel.
- For first responders in the National Park Service
- 888-918-3332
- Support offered via phone
- Fully confidential
Wildland Firefighter Foundation Mental Health Program
The Wildland Firefighter Foundation Mental Health Program has been created specifically for the wildland fire community. They provide free, immediate and confidential support through licensed therapists who are experienced in wildland fire.
- For assistance
ResponderStrong
Resources for responders to help find answers to questions, access to self-assessments, mindfulness practice and much more. ResponderStrong believes in giving responders access to tools to protect against emotional and mental health exposures.
If you or a loved one are in crisis, you can text BADGE to 741-741 to connect confidentially with a trained crisis counselor.
Substance Abuse and Mental Health Services Administration (SAMSHA)
SAMSHA Disaster Distress Helpline provides a 24/7 crisis counseling for those affected by natural disasters like wildfires.
Call 800-985-5990
Warmline
Warmline is an organization that is staffed with peers that you can call and have a conversation with, when you are not able to talk with friends, family or coworkers.
This Day in History - 6 Minutes for Safety - Grant West Rx
This Day in History is a brief summary of a powerful learning opportunity and is not intended to second guess or be judgmental of decisions and actions. Put yourself in the following situation as if you do not know what the outcome will be. What are the conditions? What are you thinking? What are YOU doing?
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Duration:13 minutes, 21 seconds
Detailed look into the Grant West Incident Staff Ride. Learn from Subject Matter Experts and people who were present at the incident on October 2, 2004, describe their experiences and perspectives.
Where this belongs
- Sequoia & Kings Canyon National Parks
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