Fire experts fault Forest Service's own probes

As the U.S. Forest Service wraps up its investigation of the Thirty Mile fire that killed four firefighters July 10, even the agency's supporters say its system for investigating deaths from wildfires is deeply flawed.

Problems range from conflicts of interest inherent in the agency's practice of investigating itself to what one top fire investigator said is the habit of whitewashing findings to protect people — and the agency — from embarrassment, blame and lawsuits.

Interviews and records show there are no minimum qualifications for wildfire investigators, and that the process can obscure the truth, preventing valuable lessons from being heeded.

The problems are so persistent and pervasive that some of the service's most stellar investigators say changes are needed to avoid wasting resources and putting firefighters at greater risk.

A Forest Service official, however, said on Friday there is nothing improper about the agency investigating itself and that it has too few catastrophes to warrant a special oversight board akin to the National Transportation Safety Board, which investigates airplane crashes.

"Our safety record has kept us from having a stand-alone body for investigation," said George Lennon, director of communications for the agency. Instead, the Forest Service forms review boards headed by people from the agency to serve as "honest brokers" in accident investigations.

Lennon acknowledged that most people involved in investigations have never participated in one before, but he said their administrative experience and knowledge of Forest Service procedures compensate for any lack of investigative know-how.

And the agency can call in any experts it needs, he said.

But longtime employees say inadequate investigations produce inaccurate conclusions that perpetuate problems.

"If you don't know what went wrong, you have no way to fix it," said Ted Putnam, one of the nation's foremost experts on burnover deaths. He worked for the Forest Service for 35 years — 22 years as an entrapment investigator — before retiring in 1998.

Putnam, a former smokejumper with a Ph.D. in experimental psychology, said he helped cover up the cause of problems in a wildfire in 1976 and "bit my tongue on many more," believing Forest Service managers when they said fixes would be made internally.

"They keep telling you in investigations team that unless there is clear proof of something dangerous to us, delete it because we might get sued," he said.

But those problems — which sometimes involved incompetent leaders — are seldom remedied, he said, and "mediocre investigations" conducted by inexperienced people continue to compromise firefighter safety.

None of the experts contacted would comment on the Thirty Mile fire investigation; a report is expected in the next few weeks.

The July 10 blaze along the Chewuch River in the Okanogan National Forest trapped 14 firefighters, killing four of them.

A 21-person team, which includes two investigators from the federal Occupational Safety and Health Administration (OSHA), has gathered information and interviewed more than 100 witnesses. OSHA is expected to issue its own report on whether the agency had adequate safeguards.

One of those witnesses, a rookie who was one of the 14 trapped, said the two investigators who interviewed him failed to ask about important factors like the establishment of lookouts and escape routes.

"I went back to the investigators after they interviewed me," said Matthew Rutman, 26. "I said, `You didn't ask the right questions.' "

The investigators took abbreviated notes of his comments, but did not tape the interview, he said.

Started in 1910

Stephen Pyne, an environmental historian and professor at Arizona State University who has written widely about firefighting, said the Forest Service is opening itself to criticism even if it conducts investigations with integrity.

"Right from the beginning," Pyne said, "the agency has been allowed to act as its own jury and judge itself."

Modern day wildfire investigations were born in 1910, he said, when 78 firefighters were killed battling flames in the northern Rocky Mountains. At the time, there was no worker compensation for wildfire crews. Their families had to seek an act of Congress to receive death benefits.

But Congress received contradictory reports about the deaths, and passed an act requiring an investigation before the benefits were paid, Pyne said.

"The agency felt it was under political attack," he said. "It did what any organism would do in those circumstances: It curled up."

As fire science became a specialty, the Forest Service incorporated scientific methods into its investigation. But it never created a process for bringing in outsider objectivity, Pyne said.

Only after 14 firefighters perished in the 1994 South Canyon Fire on Colorado's Storm King Mountain was an agency outside the wildfire community — in this case, OSHA — officially asked to scrutinize safety issues related to firefighting on the nation's public lands, he said.

OSHA issued harsh judgment of the Bureau of Land Management, the agency in charge of suppressing the South Canyon fire, and the Forest Service, which supplied equipment and personnel.

Both were cited for safety violations, and managers were accused of "plain indifference" toward the safety and health of employees.

Issues raised in South Canyon

The fire investigation was a contentious affair that changed the training regimen for firefighters and raised questions about the integrity of "in-house" investigations.

Putnam, the burnover expert, refused to sign the report because he said it "whitewashed" key events and contributing causes of death.

"With South Canyon, we didn't tell the whole truth in the first place, and the whole solution that word would get out and we'd fix things never happened," he said.

For example, the report said the fire burned for two days before firefighters were assigned to it because other fires were given priority.

But Putnam said the delay was caused by long-standing tensions between the local district and the area's fire-coordination center. Those tensions, he said, had been identified in previous audits but never corrected.

The probe also ignored the poor fitness level of a key member of the smokejumper team, he said. That person was leading 11 others in a footrace against flames later calculated to be climbing six to nine feet per second.

"They may have lost 12 people because one person was out of shape," he said. Two others died on another part of the mountain.

Putnam said the finding could have driven more stringent fitness standards for firefighters in midseason, but the team was dismissive of the theory. Later, when information confirmed the scenario, he was told not to bring it up or share the information with the firefighter's family.

He said lengthy interviews with witnesses were reduced to single paragraphs, and that someone could learn more from news accounts that quoted witnesses than from official notes.

Richard Mangan, a retired fire and aviation-program leader with the Forest Service in Montana and one of the agency's best-known investigators, said he, too, found fault in the South Canyon investigation, including his own involvement.

Mangan said he had personal connections to two people killed in the fire, and had worked as fire-staff officer on the Ochoco National Forest, where nine of the dead were based.

"I knew I shouldn't be there," he said. "It wasn't the right thing to do, but there was nobody else."

The investigations team also included a former manager for the district. Mangan said he perceived the man was trying to protect the agency from blame.

"There was a tremendous amount of political pressure for us to get a report out in 45 days," Mangan said. He said he and Putnam argued for more time, but they were "overridden at a political level."

A more definitive account of the incident was published in September 1998 after Mangan, Putnam and five others continued to pursue the investigation as a research project.

"The intent is not to find blame," Mangan said. "You don't want to ruin someone's career because of one day, one event or one mistaken management position.

"The intent is to find out what went wrong and fix it."

Putnam said there is a reluctance to blame people or name names because those involved have "suffered enough."

Lee Belau, retired fire-management officer for the Sequoia National Forest in California, said there is a practical reason for not blaming people publicly.

"If every time there was a fire, you found somebody to hang, you would have people reluctant to make decisions, and that's dangerous," Belau said.

Other agencies' oversight

All federal agencies are required to investigate fatalities under their jurisdiction. Most of those investigations are conducted by OSHA.

Some agencies, including the Department of Defense and the Department of Energy, have opted to conduct their own death and injury investigations through their safety and health departments, said Dale Cavanaugh, acting area director for OSHA.

The two investigators from Cavanaugh's OSHA office are listed as members of the Thirty Mile investigation team, but their participation is mostly to make it easier to collect information for their own investigation.

Mangan said the oversight issue is less critical than the persistent lack of expertise among insiders who become investigators.

Fire departments that investigate building fires began adopting minimum qualifications for investigators about a decade ago. No such standards exist for those investigating fires on public lands.

Paul Steensland, senior special agent with the Forest Service's law-enforcement and investigations unit, is heading an effort to change that.

But the proposed standards would apply only to investigators who determine where and how a fire started, not those looking into complex questions about other contributing factors.

In an unpublished article on fire safety, Putnam wrote that unless the Forest Service is willing to engage in a search for truth through quality investigations with qualified people, firefighters will always be sold short.

"We will continue to put people at risk if we never learn from our mistakes," he said.

Reporter Craig Welch contributed to this report.

Susan Kelleher can be reached at 206-464-2508.