Event Type: Date: Location: Chainsaw Operations Resulting in Broken Leg Background When is a quick informal briefing appropriate?

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1 Facilitated Learning Analysis Event Type: Chainsaw Operations, Wind Damage, Medical Emergency, Broken leg Date: April 30 th 2015 Location: National Forests & Grasslands in Texas Sam Houston National Forest Chainsaw Operations Resulting in Broken Leg Background On Monday, April 27 th 2015 at approximately 04:30, a strong thunderstorm blew through the Sam Houston National Forest. This storm caused significant resource damage to the northwest corner of the district cutting a path approximately 8 miles long and 3.5 miles wide. According to the local RAW station, sustained wind speeds were recorded at 35 to 40 mph with gusts of mph, and included rainfall rates of approximately 2 inches per hour. Some trees where blown over at the base while others were snapped off approximately feet above the root crown. This resulted in several state, county and forest service roads being blocked by downed trees and power lines, in addition to reports of trees falling on primary residences. The affected roads are considered primary thoroughfares for emergency access, commercial truck traffic and general public. With the recent expansion of the Houston metroplex an increase of development has occurred in and around the Sam Houston NF. This development has created a mass influx of population and traffic on the road system through the National Forest. A majority of the roads in the area are being used as primary travel routes from subdivisions in and around the forest to the Houston metroplex. As employees trickled into the duty station and the magnitude of the event became more apparent, the District Ranger called a staff meeting with the available personnel to conduct an When is a quick informal briefing appropriate? Is a high familiarity and comfort level with tasks and assignments an appropriate time for a quick informal briefing? assessment of the current situation and formulate a response. He subsequently identified the zone Wildlife Biologist/ORA (ORA is defined as; Other Resources Assistant includes supervision of recreation, trails, lands, special uses, minerals, and volunteers) as operations for the event. The initial response was to focus on Public Safety, Recreation Area s and traffic thoroughfares. Knowing the personnel he had and their familiarity with this type of work required, the Wildlife Biologist/ORA conducted a quick and informal briefing focused on assignments. This initial response was completed by the close of business on Monday. The availability of district personnel in the following days became limited due to priorities already established within their respected daily duties. The remaining available district personnel continued clearing and assessing roads while assessing Red-cockaded Woodpecker (RCW) habitat. 1

2 Clearing roads is not outside the normal program of work for this district. Having a long standing work force in place, the employees know what needs to be done and what they need to complete the task. The work crews consist of a dozer with operator, a swamper in a pickup with a chainsaw. The road clearing work is performed by the dozer tracking down the roadway (rock and natural surfaced roads) pushing downed trees out of the road. If the dozer cannot push the down trees, the swamper will cut the material so the dozer can push it out of the road. A farm style wheeled tractor is used on roads that are asphalt surfaced. The Story Day of the Injury Thursday morning started out the same as the last 3 days did for the folks on the ground, however all the district leadership were involved with a timber management review site visit conducted by the Regional Office. With the district leadership and the Wildlife Biologist/ ORA tied up with the review, road clearing assignments were given as a list of roads to be worked on that day. It was then left up to the senior employees to work out who was taking on what road system and who was working with what piece of equipment. The briefing that morning was very short and consisted of location of work and who was going where. Once the crews had their assignments they loaded up and headed to the field by Dozer 42 (Mike) and Swamper (George) were assigned to clear two secondary roads that lead into RCW habitat areas and a research plot for migratory birds. The clearing of these roads was necessary to aid in the assessment of the possible damage to RCW habitat and the research plots. The day was progressing well, the first road D-42 worked had a heavy loading of downed timber but the crew made quick work of it. As they moved to the second road, the crew found the amount of damage was lighter than other location they had worked in the previous three days. As D-42 started down the road clearing the downed trees they came to a gate and a discussion between Mike and George occurred about a possible research plot past the gate. They decided to continue to clear the road past the gate because of the possible research plot. They also knew the district would be conducting salvage sales in the area and the road would be needed for layout of these sales. As Mike worked down the D-42 attached to the truck with 20 foot chain With all the storms this district encounters, from hurricanes to tornadoes, district employees know what needs to be done and what we need to get it done. Just tell me where to go. ~Mike road he encountered a pile of downed trees in a right hand curve of the road. As Mike pushed the pile out of the roadway, the dozer started to get stuck in the ditch on the inside of the curve and he was not able to push one tree completely out of the road. Knowing he did all he could Mike continue down the road leaving the last tree in the pile for George to cut out of the road. George cut the top of the tree off, cleared the roadway without incident and continued down the road behind D-42. When Mike got to the end of the road he found the turnaround was extremely wet and muddy. Knowing George was in a 2 wheel drive truck, Mike told George he would get stuck if he tried to turn around, his best option was to back out to the gate and turn around on the main road. We were in the groove. We were getting it done. We did not need to talk at this point we just knew what each other was going to do. ~George 2

3 While backing out, George had to maneuver around some of the remaining brush along the ditch line/ roadbed edge that possibly contributed to some small overcorrections while backing. As a result, the truck became stuck when the back tires slipped off the roadbed into the ditch. After a quick analysis of the situation George decided that it would be best to wait for Mike to come back up the road to pull him out. Mike recognized the situation immediately upon arrival and without talking to George, pulled in behind the truck and positioned the dozer to pull out the truck. George grabbed a 20 foot long chain, attached it to the pickup tow hitch and then to D-42 s winch cable Impact tree hooked to a winch to simulate conditions and bind hook. George jumped back into the truck and waited for Mike to start pulling the truck. As the truck was being pulled from the ditch, George could feel secondary tension from within the driveline of the truck but was not sure what the issue was. George waved to signal Mike to stop pulling. By the time Mike stopped pulling and backed off the tension of the chain the truck was back on the roadbed. At this time both George and Mike discovered that the bumper of the truck had become hung up on the top of a tree. Additionally, there was another log hung up in the undercarriage. George immediately started attempting to remove the log from the undercarriage of the truck, while Mike (a C Certifier qualified sawyer) used George s chainsaw to cut the tree top off the bumper. Mike started his cut on top to help relieve the little tension that he thought was present and then proceeded to cut from the bottom to finish the release cut. Approximately half way through the release cut the top violently snapped from a side bind striking Mike in the left shin just below the knee. The action swept Mike off his feet and carried him approximately 6 feet backwards, forcing him to fall face down into the mud. Completely stunned by what he just witnessed George immediately asked Mike if he was OK. Mike replied, No, my leg is not right. I think it s broke! Photo showing damage to the front bumper by the top of the tree and pulling of the dozer. Also showing is the second log stuck under the passage side of the truck. Medical Emergency Clear all Traffic White flagging indicates position of tree prior to the cut, Pink flagging indicates estimated location of Mike while cutting facing the truck, impact tree is to the left of the flagging, the distance between the flagging and the cut point of the impact tree is 7feet 7 inches George used his cell phone at 10:58 (time is per cell phone call log) and called the District Assistant Fire Management Officer (John) and informed the John of the possible injury to Mike, their location and requested medical assistance. John was at the district office when he received the phone call. He informed the front desk personnel of a medical emergency, the location, request they notify the District Ranger and that he will call 911 to coordinate a response. The Front Desk called the District Ranger on his cell phone and informed him of the medical emergency and requested him to return to the office. Immediately the District Ranger called the Forest Supervisor and briefed him on the accident and relayed the information he had. The District Ranger at the time was in the field with the Regional Timber Review Team and members of the At the time of the medical emergency the land line phones were not working at the district office, all phone communications had to be conducted via cell phones. 3

4 Supervisors Office. They immediately ended the review and headed to the district office. Meanwhile, John headed to his truck to respond and called 911 from his cell phone. When the 911 dispatcher answered the AFMO immediately recognized the voice of the Using cell phones to call 911, the call goes through the closest cell tower then is transferred to the county 911 center in which the cell tower is located. This may transfer the 911 calls to the wrong 911 center, causing delay to response due to calls needed to be transferred to the appropriate 911 center. dispatcher, this familiarity with the voice confirmed to him, he had the correct 911 center. John reported the medical incident to the 911 dispatcher and requested medical and fire department personnel (EMS) to respond to a predetermined road intersection so he could escort them to the accident site. At 11:00 (per dispatch log) John called the Forest Dispatch center over the district repeater, declared a Medical Emergency and requested the repeater be cleared for emergency traffic. John informed the Forest Dispatcher he had already contacted 911 and EMS was en route. The Forest Dispatch Center initiated the Forest Accident Notification Protocol. Due to the relationship John has with the local fire departments, the Battalion Chief on duty for the day called John on his cell phone and they discussed the location of the accident, the best way to get to the site and what radio frequency they would use to stay in radio contract while they responded. John also told the Battalion Chief he would indicate the route with Yellow and Black flagging. As EMS was on their way, the Front Desk personnel started the paperwork for medical treatment and called the Albuquerque Service Center (ASC). They used the emergency option, option 5, and were able to get a representative on the line immediately to assist them. This facilitated the attainment of an Office of Workers Compensation Program (OWCP) case number, case worker, case worker s direct phone line/ contact information and paperwork for treatment faxed to the Emergency Room (ER) before EMS arrived at the accident site. At 11:22 John arrived at the accident site and conducted a quick assessment and found Mike conscious, alert with no labored breathing and not bleeding. The road leading into the accident site was too muddy for the ambulance so John used his 4 wheel drive truck to transport responding EMS personnel and their equipment to the accident site. At 11:28 EMS personnel were on site with Mike and conducted a thorough assessment. It was determined the best course of action was to load Mike into the back of John s truck and drive him to the waiting ambulance. By 11:47 Mike was in the ambulance, on his way to the regional medical center for treatment, arriving at the emergency room at approximately 12:25. Upon examination by the ER physician it became evident the sweeping motion of the tree released with enough force to break both the tibia and fibula in three places. John has worked on the district for several years. During this time he has built a strong working relationship with the 911 centers in the area and with several of the local fire departments. Some of these relationships have developed into friendships. The portion of the tree making contract with Mike s left shin was 7 inches in diameter Cutting blown down trees is the hardest and most complicated cutting we ever do, it s more dangerous than falling trees. Blown down trees have crazy bound up binds and you can t see everything. If it can happen to one of the most experienced sawyers we got, it can happen to any one of us. ~District Employee 4

5 What was learned? Take as much time as you fell is needed to make an assessments of the situation especially when conditions change Take a harder look and don t rely on the obvious clues Walk the full length of the tree out if you cannot see both ends of the potential hazard Do not let the fact you have all the gear on for one task drive your decision making process o Pull the truck forward instead of using the chainsaw to cut the tree from the bumper Even if you have all the training and experience, accidents can still happen The full blow down event needed to be run as an incident with full briefings and coordination until it is no longer an incident What Helped Make Things Go Right During This Medical Incident? The working relationship John has with the local Fire Departments, EMS and 911 Centers helped facilitate an expedited response and primary treatment. The proximity of several Paid/ Career Fire Departments to the accident site The calmness of John and Mike throughout the incident helped keep all involved calm and focused on the tasks assigned Working in pairs aided in quick notification of the accident Personnel on site were not being bothered by excessive cell phone requests for information George had first aid equipment and materials on site to make Mike more comfortable while waiting for EMS to arrive Letting trained personnel, no matter their job title or position, handle coordination of the response to the incident District Leadership: o Trusted employees to manage the accident o Provided support when it was asked for o Stayed in the leadership lane o Did not get into the operational side of the response, helping to limit confusion and kept command and control of the response seamless. Having an agency representative assigned to assist with paperwork and OWCP issues It needs to be highlighted due to the response to this medical emergency from the time of injury to arrival at the Emergency Room was approximately 1 hour and 30 minutes. Due to the location of the accident and conditions of the road system, this time frame is to be considered extremely fast and well-coordinated by John 5

6 What is your District s Emergency Medical Response Protocols? Does the protocol rely on key personnel to be effective? In coordinating the response John used the Emergency Medical Response Protocols that are listed in the Prescribed Fire Burn Plan (Element 13) for the area D-42 was working. John had written this burn plan several times making the protocols intuitive for him. This familiarity facilitated the quick response and transportation to the next level of emergency care; however this response relied on John, his knowledge of the area and relationship with local EMS. During the review of this incident it was discovered the Emergency Medical Response Protocols for this district relies on key district employees to be available for an effective response. While interviewing district employees about medical response protocols, it was discussed that employees rely heavily on the Program Managers and the District Safety Officer should an emergency arise. It also became evident that the Program Managers and District Safety Officer assumed that all of the district employees have the same level of knowledge and experience about emergency protocols as they do. While this assumption did If one of my crew was to get hurt I would call 911 and hope I get the right county. If not I would get them to the hospital as fast as I could. After that, I am not really sure what I need to do, guess I would call our supervisor at some point. ~ District Employee At this point the What if questions must be asked, What if the AFMO could not be reached? Would the response have been as well coordinated, or as fast? What if the AFMO was the one injured? What if this occurred on a day with minimal staff, on a weekend and Dispatch was not staffed? Are YOU asking WHAT IF? not affect the outcome during this particular incident, several of the employees on the district feel if these key employees are not available, they are not fully informed, trained or prepared to coordinate an appropriate medical response. These employees were asked if they had any suggestions to help improve their ability to respond to an emergency. Employees Suggestions: Evaluate first aid kits provided to crews working in the field, ensure they are adequate A written Emergency Response Protocol needs to be posted at the front desk and provided to all employees for review Emergency contact information needs to be updated and posted for all levels of Forest Management including cell phone numbers Development of training for Emergency Response on the district Train all levels of district employees on emergency response (sand tables) Ensure that the District s emergency protocols and procedures are known at all levels of the Forest Develop a redundancy into emergency response protocols Support of employees attaining a higher level of first aid training FLA Team: Team Lead Dale Snyder- AFMO/ Forest Chainsaw Coordinator/ C Certifier- Angelina/Sabine National Forests Subject Matter Expert Robert Manry- Dozer Operator/ C Sawyer- Davy Crockett National Forest Writer Editor Frank Stranimier- Lands, Minerals & Special Use s/ B Sawyer - Sam Houston National Forest 6