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Investigative report on a Cal Fire rollover in 2007

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16 years 1 month ago #22093 by IronAppraiser
Perhaps this has been read and discussed on this board so please excuse me for rehashing it if it has. Tonight I was looking at the Cal Fire web site and found this investigative report that profiled in depth a fatality and the causes of the fatality last year involving a D6N-XL. While I know this does not pertain to the hobby of collecting and operating pre 1960 Cats it does remind us that accidents are usually the result of several small things going wrong that set the stage for the bigger event.

www.fire.ca.gov/fire_protection/download...Summary_Complete.pdf

JWE

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16 years 1 month ago #22104 by equipdriver
I didnt know that had happen so close to me. There was another big fire there this year but hopefully they didnt lose any body. I can now see why one would wear a full body harness and helmet in that situation. I still think it would be very interesting to do the fire dozer work. Not for the fire fighting glory but because the areas you get to go in and see is impressive. And I like doing steep hill side work.

Karl

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16 years 4 weeks ago #22123 by OzDozer
After reading the report, I can only see one major over-riding cause of the fatality - an operator who had not been fully trained to use the tractor he was operating, and who lacked experience on that same tractor.
When he ended up in a dangerous position, he undertook inappropriate moves that resulted in the rollover and his death. All the other accident factors were minor factors.
Whoever placed this operator on a tractor that he was not capable of controlling, in all situations .. and in particular, in dangerous situations .. is as responsible as the operator himself, for the fatality.

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16 years 4 weeks ago #22156 by Rome K/G
Replied by Rome K/G on topic fatal crash
"Mans Got to Know His Limitations" (Clint Eastwood)

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16 years 4 weeks ago #22162 by D4Doug
Replied by D4Doug on topic Fire accident
Having done quite a bit of wildland firefighting and a little cat skining I think this is rather typical of wildland firefighting accidents. The fire is at an early stage where overhead is lacking, comunications are poor, and pride is invovled. Training dictates that one doesn't do what they are not trained for but nearly every firefighter has been placed in similar positions before and they have managed to overcome the difficulties. There is always resistence to get on the radio and ask for help. All firefighters love to talk about the mistakes of others as if they would have done something else. Basically the dozers were committed to a one way down hill run once they got on slopes that steep. There should have been a dozer boss sizing up the terrain and marking out the route. Dozers can not back up much of a slope. Hand held radios are great but almost impossible to hear in a dozer. Adrenaline is also high making it hard to slow down. These things are just going to happen. Sadly, even if someone on the ground had tried to stop him, it is doubtful that unless the dozer operater knew the person giving the orders that they might have been ignored in the stress of the situation. It is very difficult to give orders to a stranger is such a situation. The basic rules of wildland firefighting are to always have lookouts, escape routes, safety zones and communications. The dozer operators had no lookouts, they had no way to escape and they refused to go to a safe place, and they had poor communications. Most accidents are similar to this one.

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16 years 4 weeks ago #22172 by Dunefanatic
Report was intriging to see how Cal-Fire wrote up the sequence of events, operator dialogue, and RC to roll-over leading to operators unfortunate death. Similar to Equipment driver, this accident is in the backyard to many of us.

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16 years 4 weeks ago #22196 by Deas Plant.
Replied by Deas Plant. on topic Responsibilities.
Hi, Folks.
I have read that report before. I'm mostly with OzDozer here. Lack of training and experience on the machine in question, which was normally the other operator's machine, was the major contributing factor here. There are a couple of questions that I personally would like to see answered.

1. Who assigned the deceased operator to a dozer with which he was unfamilar, especially in view of the fact that his normal machine was available and that the normal operator for the overturned machine was also available?

2. Why was that assignment made in view of the fact that the regular operator for that machine WAS available and that the deceased's normal machine was also available?

How-wevver, I would add another contributing factor that it is now too late to change for this particular operator, attitude. He put himself and the machine at risk because he 'had' to rescue the stalled machine to pay back for a previous event when he himself had been rescued by the other operator.

I would also mention that, IMHO, it is not very smart to let your machine get on an outward side slope in steep country while cutting a bench or road, especially in material with known unstable characteristics, as in this case.

I am sorry that this operator has paid the supreme price but I hope that his loss is not wasted by ignoring the lessons that could be learned from these events.

I also take my hat off to all those courageous men and women who fight fires, especially wildland fires such as this one, to protect our various counties and communities.

You have a wonderful day. Best wishes. Deas Plant.

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16 years 4 weeks ago #22204 by Aaron
The CDF organization is just a ramshackle outfit, from the guy at the top in Sac, right on down to the people that run the local units, not one person in that organization will take blame for anything and its alwasy pass the buck, if someone is displeased with another person in their unit they do stupid stuff just like in this unfortunate accident sending an operator out on a strange unit when other possibilities exsist, its a get even company and they step on their own.
Their training for the private contracors is a joke, I would hope that the training that the company people get would be somewhat better, the seasonal help doesn't get much in the way of training either but somewhat better than we do, although the US forest service does not have a behind the wheel training program for the people that drive the crew buggies and engines that is real scary, some young kid running a crew buggy with 15 other people in them and no training particulary in the mountian roads no thanks.

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16 years 3 weeks ago #22236 by bullcrk,6
Replied by bullcrk,6 on topic CDF report
This is the first time i have read this report on the dozer rollover and while i agree with the number of reasons given that led to this tragic accident and the other post before mine i lean towards the fact that while a dozer regardless of model can be a very effective fire fighting tool there is some terrain where they do not belong, the big sir mountain range is one of those areas not well suited for dozers and often like aaron said in his post the personell overlooking these fires are lacking in many areas comonsense the bigest one, to many times someone put in charge of a dozer group has no idea what a dozer is capable of or the terain the fire is burning in and these people are deciding where to put in a dozer line,there will allways be operators who think they can go somewere they shouldn't for various reasons
and put themselves and there machine at risk for no good reason so it is important that the people making the decison to put in a dozerline no what there doing before comitting a dozer down a ridge it deosnot belong. in the
80's during the las politas fire i followed two 46a's an hd21 and to d6d's on a
d6b and we put in nearly 2 miles of dozer line over 100ft wide and when the fire got there it jumped it so fast your head spun, so putting a line down a ridge 20ft wide at best in brush is a ussless excersise forsure,but no matter the reason the loss of a catskiner and his machine is never good.

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16 years 3 weeks ago #22238 by OzDozer
The simple fact of the matter is, that very steep slopes are a great hazard to any machine, even dozers .. add in fire, great haste along with pressure, confusion about orders, communication problems .. and you have a situation that tests highly skilled and highly experienced professionals.

One of my nephews own and runs about 30 items of equipment, including about 25 Cats .. from D9's to D6's, and encompassing nearly every high track model, along with graders and loaders. He also runs a Positrack RC-60.
He has 2 x D6H's on permanent hire as firefighting tractors. These tractors and their operators are on standby 24/7/365, and must be on a fire site within 2 hrs of a call (night or day) from the Govt Dept that handles fires - the DEC (Dept of Environment and Conservation - formerly Conservation & Land Management - CALM).
He mostly has tractors available for backup to the 2 x D6H's, if a fire gets big. He gets special permits to move overwidth at night .. which is normally not allowed under Traffic Regulations.

We have only one smallish line of hills, just parallel to, and few miles in from, the West Australian coast .. but there are a lot of ridges, with some mighty steep slopes into gullies along it.
Naturally, fire is a frequent visitor to these areas, and Australian natural vegetation is full of highly combustible fuels, such as Eucalyptus oils, which is like kerosene, and which feeds those fires in a similar fashion.

Last year, a large fire saw both D6H's, plus the Positrack, out on the job .. in some pretty steep country. The operator of the Positrack is a well-trained and well-skilled young man. He was opening up a fire trail up the side of a steep gully, and working in some pretty extreme conditions .. night-time, great heat, extreme dust .. and a very steep slope.

This country is lateritic ironstone, full of exposed, hard boulders of high bauxite content. The operator ran into one of these partly-exposed boulders whilst pushing uphill, on a particularly steep slope.
The Positrack reared at the instant this boulder was hit with the bucket, as it was levered out of the ground. The Positrack was already on a very steep angle .. and it flipped over backwards, so fast, the operator never had time to do anything to counteract the action.

The Positrack rolled end-over-end, numerous times, back down into the gully, until it came to rest on a more level piece of ground. The operator, despite being in full harness, was injured to the extent, that he had to be hospitalised for 6 weeks.
The Positrack sustained extensive severe damage, but was repaired and put back to work, as it was nearly new.

DEP and the local Safety Authority initiated an inquiry .. and as part of that enquiry, the nephew had to answer 20 questions in extreme detail. Those questions encompassed every aspect of the accident, and are designed to weed out cowboy operators. My nephew is no cowboy .. my brother and I trained him up from a child, because I lived with his parents, as they were my business partners .. and he has been fully trained in every aspect of running contracting/earthmoving/mining operations.
The accident was one of those situations, where youthfulness, despite training, was the major cause .. due to excessive speed in the circumstances.

The last question of the 20 questions is the crucial one. It asks .. "What steps, have you taken, or will you take, to prevent a repetition of this accident? .."

Naturally, he was able to answer that question in detail, and satisfy the people in charge of DEC and the Safety Authority, that he had taken as many steps as humanly possible to prevent a repetition of the scenario.
The major steps in his answer, were .. alerting all his operators to the sequence of events, and advising them of the steps to take when faced with similar hazardous conditions. Risk assessment was also re-emphasised, as a precursor to any dangerous job.
It's called on-going training .. and it means you never stop learning, and putting into practice, those lessons learnt.

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