Relatório do Acidente ocorrido no Incêndio Florestal de Yarnel Hill

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John J. Percin, Jr. Jesse James Steed Travis Turbyfill Clayton Thomas Whitted Garret Zuppiger Anthony M. Rose Joe B. Thurston William Howard ‘Billy’ Warneke Kevin J. Woyjeck
Contents Executive Summary ....................................................................................................... 1 The Investigation Process ............................................................................................... 5 Background ................................................................................................................... 8 Part One: Factual & Management Report ................................................................. 11 Narrative ...................................................................................................................... 11 Friday, 28 June 2013 ................................................................................................ 11 Saturday, 29 June 2013 ............................................................................................ 12 Sunday, 30 June 2013 .............................................................................................. 15 Summary ................................................................................................................. 31 Analysis ....................................................................................................................... 33 Conclusions .................................................................................................................. 41 Recommendations ........................................................................................................ 44 Part Two: Learning Discussion .................................................................................. 45 Discussion .................................................................................................................... 45 Sensemaking Frame ................................................................................................. 46 Situational Awareness ............................................................................................... 47 Fireline Safety .......................................................................................................... 50 Communications ....................................................................................................... 55 Incident Organization................................................................................................ 58 Improving Resilience ................................................................................................ 60 Charge to the Wildland Fire Community ...................................................................... 60 Appendices ................................................................................................................ 61 Appendix A: Sequence of Events .................................................................................... 61 Appendix B: Fire Environment & Behavior Analysis .......................................................... 65 Appendix C: Personal Protective Equipment Analysis ........................................................ 82 Appendix D: Aviation Summary ...................................................................................... 96 Appendix E: Work/Rest & Qualifications Summary ......................................................... 105 Appendix F: Fire Acronyms & Terminology .................................................................... 108 Appendix G: Delegation of Authority ............................................................................. 112 Appendix H: Team Members & Signature Page .............................................................. 113 Appendix I: Subject Matter Experts .............................................................................. 115 Appendix J: Acknowledgements ................................................................................... 116 Yarnell Hill Fire Serious Accident Investigation i
Page 1 and 2: Yarnell Hill Fire June 30, 2013 Ser
Page 3: Andrew Sterling Ashcraft Travis Cla
Page 7 and 8: Executive Summary Nineteen firefigh
Page 9 and 10: included a doubling of fire intensi
Page 11 and 12: The Investigation Process Following
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
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Some Questions for Ground Crews and
Page 63 and 64:
something they thought they heard.
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wildland and WUI focus to primarily
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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
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Climate data indicates a non-typica
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directly affect the fire area altho
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At 1500 MST, the FAA radar showed a
Page 79 and 80:
help detect trends in fire behavior
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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
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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
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2. PPE Items: a. Clothing: Back of
Page 99 and 100:
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
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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
Page 111 and 112:
Appendix E: Work/Rest & Qualificati
Page 113 and 114:
Position Required Training FFT2 No
Page 115 and 116:
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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