An Arizona commission that oversees workplace safety blamed the state's Forestry Division on Wednesday for the June deaths of 19 firefighters, saying state fire officials knowingly put protection of property ahead of safety and should have pulled crews out earlier.
The ruling by the state Industrial Commission came after its investigative agency, the Arizona Division of Occupational Safety and Health, released its findings and recommended citations and financial penalties. The commission levied a $559,000 fine.
The ADOSH report was a stinging rebuke of an earlier investigation commissioned by the Forestry Division, which found that state fire officials communicated poorly but followed proper procedures when 19 Granite Mountain Hotshots were killed in a blaze near the small community of Yarnell northwest of Phoenix.
All but one member of the crew died June 30. The Hotshots were trapped as the flames they were battling changed direction in a fierce thunderstorm. The Arizona State Forestry Division oversaw the fight against the blaze that sparked on state land.
The ADOSH investigation found that state fire officials lacked key personnel to battle the Yarnell Hill Fire at critical times. Marshall Krotenberg, the safety agency's lead investigator, told the commission there should have been officers to ensure firefighters' safety, a planning section chief and a division supervisor, who wasn't replaced after he abandoned his post.
Family members who attended the hearing sobbed softly when the names of the dead were read.
Juliann Ashcraft, whose husband, Andrew Ashcraft, was killed, said the report provides important insight.
"Finally, people that are educated, that are experienced, that have researched it and have a less biased opinion — they're just there objectively — that they get it," she said.
Krotenberg told commissioners that fire managers should have removed firefighters an hour before the thunderstorm arrived.
"The storm was anticipated, it was forecasted, everybody knew it," he said. "But there was no plan to move people out of the way."
In addition, senior fire managers had already determined that the town itself was indefensible, he said.
The commission's chairman, David Parker, said he believed the fire management team on site did everything in its power to defend the community and provide for the safety of people.
"But it's not the intention of the people that (is) in question, it's that employees remained exposed after they no longer should be exposed," he said.
Carrie Dennett, a spokeswoman for the Forestry Division, said the agency fully cooperated with the investigation and declined comment. The Forestry Division has 15 working days to appeal.
Gov. Jan Brewer's office also declined comment, citing pending litigation. The mother of one of the firefighters has filed a $36 million notice of claim against the state, Yavapai County and the city of Prescott, saying their negligence led to the death of her son.
The safety agency's review occurred simultaneously but separately from a three-month investigation by national experts into the circumstances surrounding the deaths. That report was released in September and found lapses in communication from the crew in the hour before the firefighters died. It also found that proper procedure was followed but did not say whether deaths were avoidable nor did it place blame.
The ADOSH investigation found that the state Forestry Division didn't respond to a request the evening before for two safety officers, key positions in large firefighting efforts.
Krotenberg said the oversight was the result of an unknown mistake. "Apparently, it got dropped," he said. "The ball got dropped."
Firefighting crews were still battling the fire even after the incident command post was evacuated, according to the ADOSH report.
The bulk of the proposed fine is $475,000 — $25,000 for each of the 19 deaths. That money will be paid to the firefighters' families. They were employed by the city of Prescott but working under a standing contract with the state Forestry Division for the Yarnell Hill Fire. The ADOSH investigation found that the city of Prescott was in compliance with standards for training and crew rest.
The crew members had been in a relatively safe position on a ridge top. For an unknown reason and without notifying anyone, they moved down the mountainside through an unburned area where they were trapped by a wall of flames when winds shifted the fire in their direction.
They deployed their emergency shelters but perished in the scorching heat.
The surviving crew member, Brendan McDonough, was away from the others and acting as a lookout. He might have suffered the same fate had he not been picked up by another crew leader who happened to be driving by after McDonough radioed in to say he was retreating, Krotenberg said.
"Essentially, it was in the nick of time, and he didn't have to deploy his shelter," Krotenberg said.
The report praised the Granite Mountain Hotshots for remaining "alert, unimaginably calm, thinking clearly and taking decisive action." While the crew followed most of standard firefighting guidelines, the safety agency faulted the men for not scouting or timing alternative escape routes, not having a lookout as they moved toward a ranch property identified as a safety zone, and not notifying their supervisor of their movements.
The fire destroyed more than 100 homes and burned 13 square miles before it was fully contained on July 10.
Dan Parker, whose son Wade Parker was killed, is a firefighter himself in northern Arizona. He said it's time for the state "to change the coach."
"As far as blaming somebody at this point, right now, on a personal level, I think it's futile," Parker said. "But having been a captain on a fire engine, and worked in the fire service as long as I have, I know that if I was involved in an incident where somebody was injured or killed, then my butt would have been on the hot seat and I would have been held accountable."