SERIOUS ACCIDENT INVESTIGATION (SAI)

Events triggering a Forest Service SAI include a death, 3 or more persons hospitalized, wildland fire shelter deployments or entrapments, property damage other than to aircraft that exceeds $250,000, and damage to aircraft that exceeds $1 million or results in total destruction of the aircraft. In these instances, an SAI is used to gather and interpret information to help managers understand how and why an accident or incident occurred. Recommendations are developed for corrective actions to mitigate hazards and prevent future injuries and property damage.

• 24Hr.: Ouachita Rx shelter deployment, Ouachita NF, AR
• 72Hr.: Pagami Creek, Superior NF, MN
• Texas hyperthermia autopsy report
• 72Hr: Bowles Creek Bottom, TX
• 72Hr: Coal Canyon Fire fatality, Black Hills NF, SD
• 72Hr.: Diamond Fire fatality, BIA-Ft. Apache, AZ
• Diamond Fire fatality, BIA-Ft. Apache, AZ
• 72Hr.: Mt. Emma crew carrier incident, Angeles NF, CA
• CalFire Green Sheet: backing injury
• 24Hr.: Las Conchas burn injuries, Santa Fe NF
• 24Hr.: 337 Fire fatality, TX
• CalFire Green Sheet: Fresno engine accident
• Florida Div. of Forestry
• 72Hr: Bull burnover, Coronado NF
• 24Hr: Bull burnover, Coronado NF
• Engine burnover, Cleveland NF, CA
• Smoky Hill burnover, Kansas FS
• Vehicle, Chestnut, CalFire
• Dracaea near miss, CalFire
• Haun Vehicle, CalFire
• MMM Unit Vehicle, CalFire
• Buckhorn felling near miss, CalFire
• Lessons Learned: Stove scald, Kern County, CA

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ACCIDENT PREVENTION ANALYSIS (APA)

An APA is a formal process appropriate for investigation and analysis of an accident, serious accident, or serious near-miss that has potential to serve as a warning of an institutional or cultural fault within the organization. APAs describe what happened to help illuminate any signals of predictabiity present before the accident. They also help reveal any social, cultural, or organization conditions that shaped human performance and enabled the accident. The APA focuses on the conditions that enabled the accident, not the errors that caused the accident.

• Woody Ridge RX Fire APA
• APA Guide

 

FACILITATED LEARNING ANALYSIs (FLA)

Like the After Action Review (AAR), the FLA takes the process to the next level, dissecting an event and demonstrating to employees what they should learn from the event and how they should similarly learn from subsequent events.  The FLA tells a story that others can review and use as a learning tool and in a report format that can be produced quickly for immediate use in the field.

• Prospect Rock ATV Rollover, California
• Hannagan Meadows MVA, Apache-Sitgreaves NFs
• WCT, Rhabdomyolysis, Chequamegon-Nicolet NFs
• Wenworth Falls MVA, Eldorado NF
• Salt burnover, Salmon-Challis NFs
• Snow Gate snag injury, Deschutes NF
• Bear Meadows stop-work, FS-Intermountain Region
• Employee assault, Angeles NF
• Pyramid Butte firefighter injury, Mt. Hood NF

LESSONS LEARNED REVIEW

The Lessons Learned process provides for continuous improvement at the single-unit level (crew or incident management team) through group interaction, storytelling, amd honest communications immediately following an event.  The process provides immediate verbal feedback so that changes can be effectively implemented in the field in a timely fashion..

• Ozena lightning strike, Los Padres NF
• Jesusita Fire burnover, California
• Las Conchas Fire rock injury
• Pains Bay near burnover, Alligator NWR, North Carolina
• Schultz Fire, Coconino NF