The Arizona State Forestry Division released its investigative report of the death of 19 hotshots at the Yarnell Fire June 30.
The report left more questions than it answered.
The report said all of the incident command decisions were “reasonable.” It revealed that there was a 33-minute gap in communications between commanders and the Granite Mountain Hotshot crew. It did not ask why the commanders were not in contact with this team as the wind was shifting 180 degrees, except to accept their statements they thought they were in a safe area.
It reported the crew left its safe area “in the black” where the fire already had burned and hiked into a bowl where they were entrapped and burned over as they deployed their fire shelters. Why they left the black, said Jim Karels, the state forester of Florida who led the investigation, goes with the firefighters’ to their grave.
“We don’t know that information,” he said at a press conference. “We don’t have it. That decision-making process went with those 19 men.”
The team said the crew was fully qualified, met the guidelines for rest and “followed all standards and guidelines as stated in the Standards for Interagency Hotshot Crew Operations” and Arizona State Forestry Division guidelines.” This appears to dismiss the issues raised by the Phoenix Independent Times reports that the cutback of two of the crew to part time put them out of compliance.
There is no reference to whether the crew was assigned officially by National Interagency Fire Center protocol or informally.
I have read many of these reports and talk to many of the people who do this thankless work trying to piece together what happened in a tragic situation so the lessons can be learned for future fire managers and firefighters. This report avoids blame of the managers and the firefighters themselves.
It never answered the question of why they were there.
It justified this with the 33-minute radio gap and the fact the firefighters can’t speak for themselves. It recommended another report be done that examines the human factors.
I spoke with several people who have served on investigative teams and they told me analyzing human factors is one of the key elements of these investigations. If they didn’t feel qualified, one fire manager said, they should have have added members to the team for that.
The Bureau of Land Management’s Serious Accident Investigation Chief Investigator’s Manual says the team needs to determine why the deaths happened.
“The Team must continue to ask the question why until the root cause of the each finding, and therefore the accident, is identified,” the manual says. “Many investigative teams do not do this, which results in flawed recommendations that do not get to the heart of the problem.”
On complex fires communication equipment fails, firefighters can’t always judge the weather report accurately, air support doesn’t always get to the right place and confusion often reigns. But how people react to those factors — the human factor — is at the heart of the issue a investigative report should answer. This team chose not to address it for whatever reason.