Relatório do Acidente ocorrido no Incêndio Florestal de Yarnel Hill

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