Relatório do Acidente ocorrido no Incêndio Florestal de Yarnel Hill

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their respective organizations. The Team found no indication of negligence, reckless actions, or violations of policy or protocol. This report has two parts. Part One includes the fact-based Narrative of the incident and offers the Team’s Analysis, Conclusions, and Recommendations. Part Two, the Discussion section, is meant to prompt discussion and facilitate learning. It explores multiples concepts and perspectives, in order to support the broader community seeking to make sense of the accident and to improve safety and resilience. Appendices provide technical details and other supplemental information. Yarnell Hill Fire Serious Accident Investigation 4
The Investigation Process Following the tragic loss of 19 lives on the Yarnell Hill Fire, the State of Arizona convened a Serious Accident Investigation Team. A delegation of authority letter, signed by the State Forester on July 3, 2013, charged the Team with reviewing and reporting on the circumstances leading to entrapment of the Granite Mountain Interagency Hotshot Crew (IHC). The Team included representatives from local (Missoula Fire Department, Kern County Fire Department, Boise Fire Department), State (Florida), and Federal (US Forest Service, National Weather Service) governments, as well as independent experts from across the country. Appendix H includes a list of Team members. Approach and Philosophy The primary goal of this report is to facilitate learning from this tragedy, in order to reduce the likelihood of future accidents. To this end, the Team retained some of the most effective techniques of past investigations while integrating current theory and practices. The intent of this blending is to offer to the wildland fire community the highest-quality learning product possible, in a timely manner. This report does not identify causes in the traditional sense of pointing out errors, mistakes, and violations but approaches the accident from the perspective that risk is inherent in firefighting. Leaders are responsible for guiding firefighters in consideration of the tradeoffs between safety, risk management, and other organizational goals. In this report, the Team tries to minimize the common human trait of hindsight bias, which is often associated with traditional accident reviews and investigations. The Team based its approach on the philosophy that firefighters are expected and empowered to be resourceful and decisive, to exercise initiative and accept responsibility, and to use their training, experience and judgment in their decision-making. The wildland fire community uses a doctrine approach to fire Hindsight Bias The term “hindsight bias” refers to the tendency people have to view past events as more predictable than they really were before the events took place. After an event occurs, people often believe they could have predicted the outcome of the event before it actually happened. suppression, which requires the use of judgment. An individual’s judgment in a given situation depends upon their unique training and experiences. The 10 Standard Firefighting Orders and 18 Watch Out Situations (10 and 18) are the foundation of training in fire suppression operations, but they require judgment in application. These principles, as stated below, outline the Team’s perspective regarding the use and consideration of the 10 and 18 in this report: Yarnell Hill Fire Serious Accident Investigation 5
Page 1 and 2: Yarnell Hill Fire June 30, 2013 Ser
Page 3 and 4: Andrew Sterling Ashcraft Travis Cla
Page 5 and 6: Contents Executive Summary ........
Page 7 and 8: Executive Summary Nineteen firefigh
Page 9: included a doubling of fire intensi
Page 13 and 14: Report Structure This report is in
Page 15 and 16: Figure 1. Land within the fire peri
Page 17 and 18: Part One: Factual & Management Repo
Page 19 and 20: The fire eventually jumps the two-t
Page 21 and 22: Sunday, 30 June 2013 At the 0700 br
Page 23 and 24: and State FMO, seeing that the comp
Page 25 and 26: Figure 6. Estimated fire perimeter
Page 27 and 28: with radios on the incident, noting
Page 29 and 30: Also, at about 1550, GM Lookout is
Page 31 and 32: idge one mile north of town. Resour
Page 33 and 34: with the stated intent of being bac
Page 35 and 36: traffic. He contacts ASM2 and assis
Page 37 and 38: hour after launching, they spot the
Page 39 and 40: Analysis There is a gap of over 30
Page 41 and 42: • Fire behavior observed by the G
Page 43 and 44: • Moving to Yarnell provides the
Page 45 and 46: • The fire was not below them. Th
Page 47 and 48: • They could not escape the box c
Page 49 and 50: • The Team found no indication th
Page 51 and 52: Part Two: Learning Discussion Discu
Page 53 and 54: Situational Awareness Wildland fire
Page 55 and 56: forecast or update is, the lower th
Page 57 and 58: • We found no indication that the
Page 59 and 60: One might view traveling through an
Page 61 and 62:
Some Questions for Ground Crews and
Page 63 and 64:
something they thought they heard.
Page 65 and 66:
wildland and WUI focus to primarily
Page 67 and 68:
Appendices Appendix A: Sequence of
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TIME EVENT June 30, 2013 ~0700 Brie
Page 71 and 72:
Appendix B: Fire Environment & Beha
Page 73 and 74:
Climate data indicates a non-typica
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directly affect the fire area altho
Page 77 and 78:
At 1500 MST, the FAA radar showed a
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help detect trends in fire behavior
Page 81 and 82:
Figure 16. A more pronounced outflo
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north to south affecting the fire a
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Figure 20. Wind vectors around the
Page 87 and 88:
Figure 22. Yarnell Hill Fire Progre
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DISCUSSION Deployment Site Preparat
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Figure 6. The burned remnants of a
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Temperatures: The table below lists
Page 95 and 96:
Individual PPE Analysis: Eric Marsh
Page 97 and 98:
2. PPE Items: a. Clothing: Back of
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3. Body position: The firefighter w
Page 101 and 102:
John Percin, Jr., Granite Mountain
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that the SEATs each made two retard
Page 105 and 106:
equested a second VLAT, an order SW
Page 107 and 108:
Table 2. Resource Ordering Resource
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Flight Date ATKR Gallons Origin End
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Appendix E: Work/Rest & Qualificati
Page 113 and 114:
Position Required Training FFT2 No
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WFLC Wildland Fire Leadership Counc
Page 117 and 118:
Trigger Points: Geographic points o
Page 119 and 120:
Appendix H: Team Members & Signatur
Page 121 and 122:
Appendix I: Subject Matter Experts
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Relatório do Acidente ocorrido no Incêndio Florestal de Yarnel Hill

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