"Real-time information on the location of crews and the location of the fire, if those two things had been known, this accident could have been prevented," said Bill Grabbert, a retired wildland firefighter, fire management officer and author.
The results of a three-month investigation released Saturday outline a series of missteps by the crew and commanders who were fighting the Yarnell Hill Fire, but specific causes for the deaths are not included. Grabbert said such "milquetoast-type reports" are the result of federal legislation that opened the door to firefighters potentially being charged criminally for making mistakes while battling a blaze.
"It's critically important that we learn from fires like this," Grabbert said. "But with the guidelines for writing reports like this, you end up with things being soft-pedaled. That makes it difficult, or impossible, to learn lessons that can prevent fatalities."
A year after the deadly Thirtymile Fire in Washington state, Congress approved legislation in 2002 requiring an independent investigation whenever a U.S. Forest Service firefighter dies in an entrapment or burnover. In the Yarnell case, a team of local, state and federal fire experts conducted the investigation since the Granite Mountain Hotshots worked for the city of Prescott.
Brewer, in a statement issued Saturday, said she hopes the findings can further the healing process and give guidance for firefighters in Arizona and around the nation.
Other than reviewing communication plans and tracking firefighting crews, experts say the lessons from the Yarnell Hill Fire will come only as firefighters and their commanders put themselves in the shoes of the Granite Mountain crew to understand what they were facing that day and how it played into their decision-making.
The investigation revealed more than a half-hour of radio silence that occurred just before the Hotshots were overwhelmed by flames.
It's not certain why the crew left what was believed to be a safe spot on a ridge that had previously burned and unknowingly walked to their deaths in a basin thick with dry brush. At the time they died, an airtanker was circling overhead, confused about their location. The command center thought the crew had decided to stay put in the blackened area.
Despite identifying numerous problems, the report found that proper procedure was followed in the worst firefighting tragedy since Sept. 11, 2001.
Rather than assigning blame, wildfire investigations in the last decade since the Thirtymile Fire have evolved into studies of what has worked on the fire lines and what hasn't. Experts say the review of the Yarnell Hill Fire should prompt firefighters to ask themselves questions about how they would handle changes in weather or fire behavior and logistical challenges like radio traffic and miscommunication.
One of the questions posed by the report gets to the heart of firefighting culture, said Dick Mangan, a retired U.S. Forest Service safety official and consultant.
"'What would you do if you were told to do nothing?' That's really key," he said. "All wildland firefighters — for that matter all firefighters, all police officers, EMTs, ambulance drivers — we're all driven to do good and sometimes your ambition to do good, or what you think is good, overrides your training and experience and puts you in a very dangerous situation."
While the motivation of the Hotshots to leave the blackened area are unclear, investigators surmise that the crew may have been trying to reposition themselves so they could re-engage in the firefighting effort.
By this point, the fire had reached Yarnell and all other crews were helping with structure protection and evacuations. The fire was changing direction and surging in intensity and speed as smoked filled the air and ash rained down.
Andy Stahl, executive director of Forest Service Employees for Environmental Ethics, said it was the vulnerability of Yarnell that resulted in the firefighters putting their lives on the line. The thick chaparral around the town hadn't burned in nearly a half-century, drought had plagued the area and many homes weren't defendable.