The Bureau of Land Management Freeman Reservoir Factual Report is now available
Summary
On June 26, 2009, Brett Stearns, Engine Captain of the Little Snake Field Office (LSFO) Engine 1613, was fatally injured during a tree felling training exercise. Stearns was injured by a section of the tree that broke away from the main trunk during a felling demonstration.
Stearns, 29, was an experienced firefighter and a qualified B-level Faller (FALB). The field training took place in the Freeman Reservoir Recreation Area on the Hahns Peak/Bears Ears Ranger District of the Medicine Bow-Routt National Forest 20 miles northeast of Craig, Colorado. This area was selected because of the opportunities for chainsaw use as well as the need to remove hazardous trees near a public campground.
Stearns led two trainees. Training consisted of selecting a hazardous tree, discussing and evaluating specifics of the tree (lean, direction of fall, branch distribution, etc.), any safety concerns, and falling procedures. During training, the team worked on a large dead aspen tree, approximately 68 feet tall. The team followed their established procedure; however, as the tree began to fall the crown of the dead tree became entangled with a live aspen. In the process of freeing the dead tree, the dead tree broke in two pieces and pressure from the live aspen tree catapulted the upper portion backwards directly toward Stearns.
First Aid and medical evacuation procedures were initiated by BLM personnel on site as well as the local Emergency Medical Services (EMS) personnel, and local law enforcement. Stearns was pronounced dead by the Moffat County Coroner’s Office at 5:09 p.m.
A Serious Accident Investigation Team (SAIT) was mobilized on June 26, 2009, and arrived in Craig, Colorado on June 27, 2009 to begin the investigation. This is standard practice for the bureau anytime there is a death. The team consisted of a team leader, a chief investigator, a safety advisor, two fire operations/tree felling technical subject matter experts, an interagency representative from the U.S. Forest Service, and an administrative assistant.
The team then develops a Factual Report by gathering evidence and information, which consists of visiting the accident site, reconstructing the accident site and actions, gathering written statements, conducting interviews, validating training and personnel qualifications, and reviewing time and attendance records. The team also considers and evaluates human, environmental, and material factors that may be related to the incident. And lastly, the team cooperates with other investigative agencies, and uses subject matter experts in felling operations to validate actions taken by Stearns
The SAIT based their findings on three categories: human, material, and environment.
Finding 1: Human Factor – The unexpected tree trunk fracture and subsequent catapult of the upper portion of the tree combined with Stearns’ inability to escape the area and the physical injury that resulted, were the direct causes of his accidental death.
Finding 2: Human Factor – Given witness statements, site evidence, and examination of cuts on the stump, the SAIT Subject Matter Experts (SME) determined that BLM policy and existing guidelines were generally followed by the faller, but he lost situational awareness by not maintaining visual contact with the tree until it hit the ground and by not re-evaluating the extra time needed to reach the designated escape routes from the second cut location.
Finding 3: Material/Environmental Factor – The existing LSFO Risk Management Worksheet for chainsaw operations does not adequately address specific risks for felling or hazardous tree removal procedures. A written Risk Assessment was not developed for the hazardous tasks at this site as required by BLM Handbook 1112-2, Safety and Health for Field Operations.
For the complete report click here.