1956 11/25 CA 11-Fatality Inaja

Incident Name: Inaja Fire, Palomar District of the Cleveland National Forest
Date: 11/25/56
Personnel: 11 lives lost
Age:
Agency/Organization: CDF inmates, their correctional officer and 3 US Forest Service employees
Position: firefighters

Summary:

Forest Service Firefighters
Albert W. Anderson, 45 years, Night Sector Boss (FS employee, SHF)
Carlton Ray Lingo, 19 years, Night Crew Boss (FS employee,CNF)
Forrest B. Maxwell, 30 years (FS employee, SHF)

Firefighters from Viejas Honor Camp and their CDF Supervisor:
LeRoy Wehrung, 41 years (CDF employee, Correctional Officer from Viejas Honor Camp)
Miles Daniels, 33 years
William D. Fallin, 22 years
George A. Garcia, 41 years
Virgil L Hamilton, 26 years
Joseph P. O’Hara, 45 years
Lonnie L. Shepherd, 26 years
Joe Tibbitts, 34 year

Eleven men lost their lives in a fire blow-up in San Diego Canyon on the Inaja fire, Cleveland National Forest, at 8:05 PM, Sunday, November 25, 1956. A 13 person inmate crew from from Viejas Honor Camp, their correctional officer, and 4 FS firefighters were cutting indirect line in the steep canyon west of Julian CA. Upslope winds increased in the evening when the Santa Ana winds ceased. Fire hooked under the men before they could reach safety at the top of a steep chimney. One Forest Service employee and six inmates escaped uninjured. However fire flashed over in an uphill run and 7 inmates, their correctional officer and 3 FS Firefighters died.

About the fire, from the report: Before being controlled at 6:00 pm, November 28, the fire burned 43,611 acres within the Cleveland National Forest and adjoining land protected by the State and burned at least 5 homes. More than 2,000 men fought the fire, 1,300 under Forest Service supervision. These included 500 Indians (local and Southwestern Region), about 500 Navy personnel, 200 inmates from San Diego County and State Honor Camps, and other organized crews. These men plus 3 helicopters, 4 air tanker planes, 2 scouting planes, 27 bulldozers, and a fleet of 90 stake, tank, and pickup trucks, formed one of the greatest arrays of men and equipment ever assembled to fight a forest fire in San Diego County.

From this incident came the 10 Standard Firefighting Orders 1957.

Inaja Fire Topography:

Inaja Fire Topography

Maps

Inaja Fire Origin, Cleveland National Forest

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From The San Diego Union Tribune: Map of the Inaja Fire

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Reports, Documentation, Lessons Learned

Winds and wind shifts reoccur in a typical pattern in the San Diego River Drainage. The 2007 Fireline Safety Refresher Training has a segment at the beginning Fire Indicators – Part 10 – The Cedar Fire describing these wind patterns and presented by Dennis Baldridge, supe of the Laguna Hotshots. Steve Rucker died on the Cedar Fire in 2003, approximately 2 miles up-canyon from the Inaja Fire fatalities.
Forest Service, original copy: The Inaja Forest Fire Disaster (515 K pdf)Here’s the updated and easier to read Inaja Forest Fire Report for the 50th anniversary. (415 K) (Virgil L Hamilton’s name was inadvertantly omitted.)
Recommendations of the Investigating Team
1. It was strongly brought out by the investigation that better knowledge of fire behavior must be developed as an essential means of preventing future fire tragedies. Research studies even more comprehensive and penetrating than past and current fire behavior research must be carried our to determine means of fighting mass fires and the behavior of fires in forested areas, especially in rough topography. In addition to progress in fire control methods already made, new and more powerful methods of attacking mass fires are needed and must be developed. Such methods, like use of aerial attack with water and chemicals, may provide the means of controlling dangerous fires with less risk to human lives.
2. More experts on fire behavior must be developed for assignment to critical fires. These highly skilled experts would evaluate situations and assist fire bosses in making decisions for safe, effective fire fighting.
3. The investigators pointed out that in general, although not relatedin particular to the Inaja fire, present Government salary and wage rates make it difficult to obtain and hold competent fire control personnel. Controlling mass forest fires is a difficult and highly technical job. The specifications for these positions should be further reviewed with appropriate Department and Civil Service Commission officials.

Inaja Fire Behavior (1.96 MB pdf)
Inaja Fire Summary (261 K pdf)
The policy report that came out of this tragedy is neatly laid out by Kelly Andersson (1999) in this elegant early Forest Service web page retrieved via the WayBackMachine:
1957 Report of Task Force to Recommend Action to Reduce the Chances of Men Being Killed by Burning While Fighting FireWe recently received a tidy digital copy for posting. Thanks! 1957 Report of Fire Task Force

This 1957 report was submitted to the Chief of the Forest Service by a task force including W.R. Moore, V.A. Parker, C.M. Countryman, L.K. Mays, and A.W. Greeley. Their cover letter is online.

This report marks the origin of the 10 & 18 and of the research into and use of fire behavior knowledge in wildland firefighting. This report was also a milestone in the development of both NARTC and the incident command system.

A handful of minor changes (e.g. spelling, punctuation) have been made to the online version of this report.
ROUGH DRAFT
AWGreeley:mlm
6/17/57

REPORT OF FIRE TASK FORCE
Introduction

This report is submitted in response to the Chief’s F-CONTROL Suppression memo of April 12, 1957. By that memo, the Chief appointed a task force to study ways the Forest Service may strengthen its efforts to prevent fire fatalities.

Objectives: The task force was given these definite assignments:
1. Recommend further action needed in both administration and research to materially reduce the chances of men being killed by burning while fighting fire.
2. Recommend ways to develop experts in fire behavior.
Since this study has been purposely centered on fire fatalities by burning, we have not reviewed general safety practices nor injuries due to causes other than burning. However, carrying out the recommendations made in this report will probably be very beneficial in improving the general level of safety practice in fire suppression. (read the rest of )
Ted Putnam: Ten Standard Firefighting Orders : Can anyone Follow Them? 2/2/02
Forest Service Heroes List: Memorial page for 1956

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Wildlandfire.com Links:

Too many to list, we used the hotlist on wlf.com search button to search the Hotlist on Inaja
Hotlist: On the 55th anniversary
Theysaid: 12/5/11 thanks for Inaja reports, photos, info

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Media Articles and Reports.

Fallen firefighters named:

Fallen firefighters named Inaja incident

Deadly 1956 chaos led to ‘firefighting orders’
From The San Diego Union-Tribune: Link to Online Article
By John Wilkens, UNION-TRIBUNE STAFF WRITER
November 25, 2006

Working at night, the men were trying to cut a control line around the fire when it turned on them. They dropped their tools and ran. The flames were faster. Eleven firefighters died.

The Inaja tragedy happened 50 years ago today in San Diego’s backcountry, and it changed how wildland fires are fought in America. In a way, war was declared. There was a new determination to understand the enemy, and new rules of engagement for firefighters.

Since then, there have been more changes: more gadgets and more sophistication. But the rules – the Ten Standard Firefighting Orders – have endured and become, in the words of one expert, “almost a sacred text.” With pointers about weather, escape routes, lookouts and communication, the rules are taught early on to every new firefighter and drilled into firefighters’ heads through repetition for the rest of their careers.

The orders are printed on laminated cards they carry in their wallets and on stickers they put on their helmets. The orders are painted on the walls of fire stations. “They are the building blocks for everything we do,” said Carlton Joseph, a Rancho Bernardo-based deputy fire chief for the Cleveland National Forest.

But foundations sometimes shift, and there is an ongoing debate in the fire service about the effectiveness of the rules. Some say more emphasis needs to be put on training firefighters to make sound decisions under stress, instead of expecting them to follow orders.

The debate rises whenever there’s another fatality, such as last month’s Esperanza fire that killed five firefighters in Riverside County. Investigations of fire deaths typically include an evaluation of whether the Standard Orders were followed; authorities have announced that will be part of the Esperanza probe.

That, too, is controversial, said Jennifer Thackaberry Ziegler, an assistant professor of communication at Purdue University, who has studied the orders extensively.

Victims’ families sometimes decry the way the orders are used “as a checklist for blame in investigations,” Ziegler said. “Citing the number of orders violated tends to direct attention to what the firefighters on the ground did, as opposed to organizational factors such as whether the safety training they receive is effective.”

The Inaja fire came just three years after 15 firefighters were killed in the Rattlesnake fire in the Mendocino National Forest, and seven years after 13 smokejumpers died at Mann Gulch in Montana. Inaja was “the straw that broke the camel’s back,” Ziegler said.

The fire was started by a 16-year-old boy on the Inaja reservation, who later told investigators he “got a crazy idea” to throw a match into the grass to see if it would burn. By the next afternoon, the fire had consumed about 25,000 acres, burning north toward Pine Hills and west to the El Capitan Reservoir. Crews were sent to cut containment lines.

At about 7 p.m. on Nov. 25, a night crew arrived at a steep canyon along the San Diego River, about nine miles southwest of Julian. Most were volunteer firefighters, inmates from the Viejas Honor Camp. The men were cutting and scraping a line from the canyon rim to the riverbed. The fire was on a side ridge, roughly 1,000 feet below them. It flared suddenly, jumped into a ravine and raced toward them.

A crew boss near the rim saw the flames and told the crew to flee. Six men made it out, but 11 were engulfed by a “flash-over,” a simultaneous ignition of gases generated by the fire as it roared up the canyon. Of those killed, three worked for the Forest Service, seven were honor camp inmates and one was a guard.

In early 1957, Richard McArdle, chief of the Forest Service, created a task force to study Inaja and other fatal fires and recommend ways to improve safety. The group issued a 30-page report that highlighted the need for better training, especially in fire behavior.

“Up until then, there wasn’t much training or technical information available,” Joseph said. “They realized they needed more expertise so they could anticipate what a fire might do.” Borrowing an idea from the military, where “General Orders” guide soldiers, the task force also recommended implementation of Standard Firefighting Orders. McArdle approved them, and their use became widespread. “You learn them the first days of training,” said Bill Clayton, a local division chief with the California Department of Forestry and Fire Protection. “If you don’t learn them, you do a lot of push-ups.”

At the time the orders were adopted, an average of six wildland firefighters were fatally overrun by flames each year in the United States. By 2003, that number had dropped to two per year, according to a Forest Service study. Many credit the Standard Orders and a string of other innovations – training, weather equipment, fire shelters, attack helicopters – with helping to save lives.

The devastating Cedar fire in 2003 started only about 1½ miles away from where the firefighters died in the Inaja blaze in 1956. Joseph said Inaja was on his mind as he helped direct the forces battling Cedar. “It was one of those slides in the slide tray,” he said. “It played into the decision-making there.”

Part of the connection was personal. His father, Kenneth, worked for the Forest Service on Inaja. He was the crew boss who saw the flames and urged the men to get out of the canyon. He survived, but his best friend, Carlton Lingo, didn’t. Carlton Joseph is named after him. Another part of Joseph’s thinking on the Cedar fire stemmed from the Standard Orders. They helped determine what not to do: send crew members into the San Diego River canyons to fight the fire by hand that first night.

“To hike people in, with no escape route and no safety zones (both required under the Standard Orders) – we don’t do business that way,” he said. “Had we put people in there, something similar to what happened before might have occurred there.”

Most veteran firefighters have similar stories. Patrick Withen, a University of Virginia sociologist who has worked 24 summers as a smokejumper, said he’s been in tricky situations where the orders pop automatically into his head: “Now where exactly is my lookout?”

But some of the orders can also be frustratingly vague, Withen said. The last one, for example, says, “Fight fire aggressively, having provided for safety first.” Asked Withen: “How do you use that?”

Compounding the problem, the Standard Orders aren’t the only list firefighters are supposed to know. There is also a list of 18 potentially dangerous situations; another with seven rules concerning downhill fire-line construction; four common denominators of wildland fire tragedies; the LCES (Lookouts, Communication, Escape routes, Safety zones); and others. Withen added all the rules once and came up with 59.

Some of the guidelines overlap. A few years ago, Withen proposed consolidating them into 10 “essential” factors in wildland firefighting that could be monitored for safety during a blaze. He said he’s received positive feedback from other firefighters, but no official endorsement.

Controversy about the effectiveness of the Standard Orders has been swirling since 1994, when 14 firefighters perished in the South Canyon blaze in Colorado. The investigation blamed a “can-do” attitude that led crew members to violate eight of the 10 rules. “There was almost a moral outrage on the part of the investigators that the rules had been broken,” said Ziegler, the Purdue professor. She said fire administrators “lowered the boom,” issuing edicts that the orders should never be violated.

One of the investigators, Ted Putnam, a Forest Service firefighter and equipment specialist from Montana, refused to sign the final report. He argued that the orders are flawed and too easily used to point fingers – a way for management to avoid responsibility for shortcomings in organization and supervision.

He said more attention should be paid to the “human factors” on a fire line, such as sleep loss and fitness level, and that better training is needed for decision making in stressful conditions. His feelings were echoed in a subsequent survey of wildland firefighters. They urged development of “a safety culture that encourages people to think rather than just obey the rules.”

Forest Service officials are moving in that direction, with more training in situational awareness, leadership and risk management. “We’re not there yet, but we’re making strides,” Joseph said.

Nobody expects the Standard Orders to disappear anytime soon.

“It is almost a sacred text,” Ziegler said. “It means a lot to firefighter culture, and people are afraid to change it. The orders are traditional. They function, in a way, as a memorial to the dead.”

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Photos, Videos, & Tributes

“Surely these men gave their lives in defense of this country, for without the strength of our forests, water, and other natural resources, this Nation would not be a leader in the free world today.” — Richard E. McArdle, Chief, Forest Service
Inaja Fire Memorial Monument in Nuevo Cemetary in nearby Ramona: To Leroy “Jack” Wehrung
Inaja Fire Memorial Monument off HWY 79 near Santa Ysabel in a small picnic grove: To all the men who lost their lives that day The monument is here among the tables and barbecue pits and with a vantage point where one can view the canyon where this tragedy occured.Picnic Ground Sign | Picnic Ground with Monument | 11 Names on Monument | Hwy 79 at Turnout

Ten remains were claimed by families and buried in hometowns. The body of Virgil Hamilton was never claimed and was headed to a pauper’s grave. Grateful area ranchers banded together and claimed his body which was interred in Greenwood Cemetery, San Diego with full honors.

Location of the Memorial

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