Three silviculture staff members were preparing to start burning dispersed slash piles on a cutblock. Before they started burning they completed a tailgate meeting and discussed a “burn plan”. The tailgate meeting identified hazards such as escape routes, wind speed/direction and smoke. The plan was to burn in two groups, with two of the three individuals within the same portion of the block.

The two individuals working closely together burned strategically so an escape route would be left available.

One of the two individuals ran out of fuel with a number of piles still left to burn. They both returned to the road and discussed the burn plan and identified an escape route once again. As the two individuals were working together they were getting closer to the individual off on his own and so they discussed the importance of always being in visual contact with each other. One of the two individuals returned to the truck to get more fuel while the other continued burning. When he returned a short while later from getting more fuel he noticed that the front piles had self-ignited.

As planned, the individual did not start burning as he could not see his partner. When visual confirmation could not be made he called out to his partner and explained that the front piles had self-ignited and that they should leave the area before the piles eliminated any available escape route, which they then did.

Key Learning: These individuals conducted a tailgate meeting to discuss the potential hazards and establish a work plan for the block. They established a check-in system to keep track of each other’s locations so escape routes would not get inadvertently burned away. Also, they had a “no burn” protocol if visual contact was lost between team members, which prevented this “near miss” from becoming a potentially more serious incident. Unanticipated wind activity, due to the convective nature of fire, can cause piles to spot and self-ignite. Individuals burning blocks should always reassess weather conditions as burning progresses. Burners should have walked to the back of block first then started burning so burning piles are left behind and an escape route is always available out in front.

Root Cause: The primary root cause was determined to be inadequate documentation of pile burning safety hazards and safety considerations in the Management System.