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SAFENET

Wildland Fire Safety & Health Reporting Network

SAFENET Event Information
Create Agency Corrective Action

SAFENET ID:
20160912-0001        [Corrective Actions]
Event Start Date:
08/23/2016 0800
Event Stop Date:
 
Incident Name:
Copper King
Fire Number:
P1KJ37 
State:
Montana
Jurisdiction:
USFS
Local Unit:
Plains Ranger District
Incident Type:
Wildland
Incident Activity:
Support
Stage of Incident:
Extended Attack
Position Title:
Air Operations Branch Director 
Task:
Helibase Activities 
Management Level:
1
Resources Involved:
10 Helicopters two helibases 
Contributing Factors
Contributing Factors:
Human Factors
Human Factors:
Decision Making  
Other Factors:
 
Narrative
Describe in detail what happened including the concern or potential issue, the environment (weather, terrain, fire behavior, etc), and the resulting health issue.
Summary

• A situation describing the events on the Copper King incident, where the national contracting office, directed the air operation to demob equipment that was critical to safe flight operations.

• The unsafe flight operations created by inability of contracting organization to provide adequate equipment as requested.

Summary of hazard evaluation for flight operations:
a. Flight operations on an active airport.
b. TFR adjacent to General Aviation travel route. (Canyon flyway)
c. High tension power lines in canyons
d. High winds over ridges
e. Deep canyons limiting communications with helibase.
f. Limited personnel on the helibase and multiple UTF of orders.
g. Rapidly evolving fire. (9mile run in 6 hours at night)
h. Type 3 team managing fire.
i. Aircraft located in a large geographic area on the airport.
j. mix, of all type of aircraft.

DAY 1: On 8/19/216, I arrived at Thompson Falls, Montana for the Copper King fire incident, which had three aircraft assigned. The flight operations were being conducted from the local airport out of an exclusive use Forest Service trailer using hand held radios. The flight operations unit had been on the fire for two weeks and notable issues were observed: their power supply equipment was failing, hand held radios were inadequate to receive all needed traffic, and working conditions resulted in staff physically exhausted after a 15 hour work day. During that day’s shift, the fire had increased significantly in activity. The following day, the IC requested additional aircraft, which I ordered.

My evaluation for safe flight operations on this base indicated the need for a flight operations support trailer that had an elevated 360° view and room in the ABRO area to accommodate at least four individuals. I was familiar with the DPL and knew that the first two units would not meet my needs. I asked the local equipment COR how best to receive adequate equipment. The advice was to order three and demob two. Note: I could not find any references in the contract that would deny this procedure.

I proceeded with this course of action and as the order was being filled, the Region canceled the order. This cancellation perpetuated the condition of poor radio contact and an unsafe working environment (hot/dusty/noise). One day of flight activity commenced with this risky set up. Note: By this time we had nine aircraft with 36 plus takeoff and landings a day.

DAY 2: Still no communication unit received. With this development, I asked our team AOBD and the contracting representative and the regional Helicopter specialist how best to proceed. The advice was to use an EERA. I wrote up the specifications needed to obtain equipment and placed the order through our normal ordering system.

DAY 3: I received a communication unit that fit my requirements. One hour after receiving the unit, I was directed by the AOBD to demob it. Apparently, ‘Contracting’ had ordered us to use the National Helicopter operations support trailer contract only,(DPL).

Realizing that our national contracting office was unable to provide safety equipment appropriate for our flight operation, we decided to keep the substandard unit and save the government $1,700 a day.

We mitigated our unsafe flight operation by reviewing the following options:

a. Terminating all flight operations. This was rejected as unrealistic to meet the needs of the incident.

b. Developing two helibases. This was rejected as the radio issues would not be addressed and the fire did not have overhead to manage two bases. Note: All orders for personal at this time were UTF.

c. Ordering the next unit on the DPL. It was determined to be more work to manage and was considered to have similar attributes as the unit on the base.

d. Monitoring the local Unicom frequency and asking folks to let the box know of aircraft in the area. We had the incoming type one team continue the setup of a linked radio system for aircraft.

The team ultimately received personnel to staff two helibases and two aircraft communication trailers were order per the Regional Helicopter Operations specialist, and the Regional Aviation Safety Manager who were visiting the fire and recommended that we place an order for two trailers. We received one substandard unit and placed it on the base with four aircraft and a local dispatch office that helped cover our needs. The second trailer was placed on the base that had six aircraft giving better coverage for flight operations. However, none of these mitigations reduced the frustration felt or time spent trying to receive the best equipment for a complex operation.

We understand contract rules, but when it interferes with, or is written such that the field (user) is unable to complete their mission, an unsafe work condition has been created.

Testimony to unsafe work conditions include these statements:

1. “On the second day of my assignment, we had nine aircraft located on a 4,800-foot airport and placed in front and behind the EU service trailer. We were unable to observe all aircraft takeoff and landings. We needed a unit that was high enough to look down the flight line, over aircraft and buildings that blocked our view.”

2. “Because aircraft was taking off and landing behind the unit, as well as to each side, we needed a full view of the flight deck. One unit was ordered and received, but was subsequently directed to Demob.”

3. “Constant denial of orders and changes to our resource orders by management and contracting officials resulted in a period of four and one half days that were truly unsafe and potentially life-threatening.“

We are a make-do and can-do origination. When we have the ability and tools to complete a mission safely, but can’t due to miss-guided rules or poorly written contracts, then the system is truly broken and serious actions are required before a life is lost.
Immediate Action Taken
Reporting Individual : please describe actions you took to correct or mitigate the unsafe/unhealthful event.
Filed Safe Net and would recommend terminating contract and getting a group of SME's together to assist the contracting officer in writing a new contract that doesn't reward low bid and offers best value to field users.


Corrective Actions

20160912-0001-CA001

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