The Thirtymile Fire Fatality Incident.
On July 10, 2001, four Forest Service fire suppression personnel
were killed after they became entrapped and their fire shelter
deployment site was burned over by the Thirtymile Fire, in the Chewuch
River Canyon, about 30 miles north of Winthrop, Washington.
The area was enduring a lengthy drought and the moisture
levels in large fuels were very low. Ladder fuels were abundant at
the point of origin, on the east slope of canyon, and throughout
the canyon floor. The day of the event, temperatures reached
94° F and relative humidity reached a low of 8% on the Chewuch
River canyon floor. Slopes were steep (with slopes 70% to 100%) on
both sides of the canyon. Fire conditions were potentially
The Investigation Team identified a large number of findings based on
their review of the events that led to the Thirtymile Fire fatality
incident, the findings have been organized into four subject
Environment of the location of the incident
Equipment involved in, or contributing to, the incident
People involved in, or contributing to, the incident
Management issues or principles associated with the incident
Summary of Significant Findings
Although there were many findings identified for each of the four
subject categories, the investigation team identified a smaller set of
findings that were considered to be of significant importance to
understanding the underlying causal factors that are associated with
Significant Environment Findings
The combination of weather (at or near historic extremes for
temperature and relative humidity, and the extended drought in
the region) and fuel conditions (complex fuels on the canyon
floor, extremely low moisture content of both the live and dead
fuels) created extraordinary circumstances for fire growth on
July 10th .
Potential fire behavior was consistently underestimated
throughout the incident.
Significant Equipment Findings
In spite of the ready availability of water, relatively little water
was applied to the fire during the initial attack phase. This was
largely due to operational problems with pumps and hoses, as well as
delays in availability of a Type III helicopter.
Significant People Findings
The fatalities and injuries all occurred during fire shelter
deployment. Failure to adequately anticipate the severity and
timing of the burnover, and failure to utilize the best location
and proper deployment techniques contributed to the fatalities
Leadership, management, and command and control were all
ineffective due to a variety of factors, such as the lack of
communication and miscommunication, fatigue, lack of situational
awareness, indecisiveness, and confusion about who was in
Two civilians were involved in the entrapment due to a failure
to properly close a potentially hazardous area.
Significant Management Findings
All 10 Standard Fire Orders were violated or disregarded at some
time during the course of the incident.
Ten of the eighteen Watch Out Situations were present or
disregarded at some time during the course of the incident.
Records indicated that personnel on the Thirtymile Fire had very
little sleep prior to their assignments, and mental fatigue
affected vigilance and decision- making.
District fire management personnel did not assume incident
command when the size and complexity of the fire exceeded the
capacity of the NWR #6 crew.
Command roles on the Thirtymile Fire were unclear and confusing
to those in command of the incident, to the rest of the crew,
and to others associated with the fire.
Additional findings noted below illustrate the fundamental finding
that incident management was confusing and unclear.
The elements of fire complexity dictated a transition from
initial to extended attack. The IC did not revise the strategy
and tactics to address these changed circumstances.
Between 3:24 and 3:27p.m Engines #701 and #704 arrived on the
fire scene and did not check in with the Incident Controller or
obtain a tactical briefing.
Although adequate time to prepare for shelter deployment was
available, leadership did not prepare the crew for a possible
burnover or initiate actions to control the situation.
The Thirtymile Fire was considered 'basically a mop-up show.
10 Standard Fire Orders
All 10 Standard Fire Orders were violated or disregarded at one time
or another during the course of the incident. The following are some
examples of these situations.
2. Initiate all actions based on current and expected fire
Aggressive attack with over-extended resources continued in
spite of onsite indicators of an increased rate of spread,
multiple spots, and crown fire.
4. Ensure that instructions are given and understood.
Instructions were coming from multiple sources adding to the
6. Remain in communication with your crew members, supervisors
and adjoining forces.
Although the communication equipment was adequate, the lines of
communications on the incident were poor due to lack of a plan
and poorly established command structure.
9. Retain control at all times.
Leadership was fragmented and ineffective at all levels during
the afternoon of July 10th.
Resources were being ordered and directions given by others than
the Incident Controller.
10. Stay alert, keep calm, think clearly, act decisively.
Supervisors, managers, and firefighters failed to stay alert and
recognize changing conditions.
Fatigue and collateral duties impeded the abilities of key
leadership to think clearly and to act decisively to use
available time on the shelter deployment site to prepare for the
Watch Out Situations
Ten Watch Out Situations were present or disregarded at one time or
another during the course of the incident. The following are some
examples of these situations.
5. Uninformed about strategy tactics and hazards
Chosen strategy and tactics were not achievable or viable due to
fuel and environmental conditions.
Hazards were never properly recognized, evaluated, and
6. Instructions and assignments not clear!
The Incident Commander did not make sure that all instructions
were complied with.
Many people throughout the incident gave instructions.
8. Constructing fire line without a safe anchor point
When action was taken on the spot fires at the head of the main
fire there was no secure anchor point.
11. Unburned fuel between you and the fire
When engaged in suppression actions on the spots there was a
large amount of unburned fuel between the main fire and the
spots about 150 to 300 yards away.
12. Cannot see main fire, not in contact with anyone who
Air attack could not see the entire fire; no one could see the
part of the fire that presented the greatest hazard.
Terrain smoke and vegetation blocked firefighters view of the
A look out who could continually view the main fire was not
Safety is an uncompromising master. Most people compromise safety
routinely in their daily activities, usually with no consequences.
But neglect of safety eventually leads to 'near misses', and 'near
misses' lead to accidents, some with tragic consequences. Fire
suppression can be a dangerous business, and it has a history of
tragic deaths. Safety and fire suppression need not be mutually
exclusive, and safety must come first.
All organizations involved in wildland fire suppression, and
especially each individual, need to rededicate themselves to the
fundamental principle that a choice for safety is the right
choice -- every time.
The above 'extract' reprinted here courtesy of the USFS
Last updated 4 November 2014