On the Lily Lake Fire August 17, 2020 on the Deschutes National Forest in Oregon, a first-year smokejumper performing a letdown procedure from a tree fell and suffered a broken vertebrae. The patient was treated on scene by U.S. Forest Service EMTs then transported to a hospital via air ambulance. Surgery three days later was successful and a full recovery is expected after rehabilitation.
Below are excerpts from the facilitated learning analysis. It begins after exiting the airplane and before landing.
Once on final [approach] he recognized that he was a little downwind from where the other jumpers had set up.
When he realized he wasn’t going to make the jump spot and no alternates were available, he looked around for a healthy tree and selected a tall green western hemlock to land in. He aimed for it, snagging his parachute in limbs approximately 40 feet above the ground. As he came to rest he quickly shifted into the muscle memory he developed during rookie training that spring, calming the initial nerves he felt.
Initiating the letdown procedure, he called out to his jump partner, “JP, am I hung up well?”
But his jump partner, still making his way to the tree having just landed himself, was not yet close enough to hear or respond. Now that he was treed up, the tree didn’t seem to be as good as he thought. Entangled about midway up the 100 foot tree on the edge of the branches, he was just out of arm’s reach from the bole. He seemed to be fairly level with most of the tension on his left riser. There weren’t many branches around him, and those that were nearby were short and sloped downward. Continuing the letdown procedure, he chose to drop the drogue release handle instead of placing it in his pocket, in order to avoid excess movement.
Three jumpers from the previous load heard over the radio someone was treed up as they continued hiking to the fire. The jump ship maintained orbit, waiting for the jumper to get on the ground before throwing cargo. One of his rookie trainers saw him hung up and ran over to help him through the letdown procedure.
He wasn’t far along in the process when she reached his tree. “Am I treed up well?” he asked.
Looking up at the suspended jumper the rookie trainer didn’t think he was and told him so, encouraging him to continue and limiting her input to only what was needed to expedite the process. As the jumper continued through the steps small branches rained down. Throughout his training he had demonstrated great proficiency in the letdown process both on the units* and during a training jump where he treed up. He felt less stress now than he had during the training jump. His rookie trainer listened as he advanced through his five point check “perfectly correct.”
He slowly released his right side riser and felt little movement. As he suspected, his left riser was holding his weight. Suddenly he had “a bad feeling” and said as much to the jumper on the ground. He then began to release his tight left riser. He had to jerk slightly on the riser to initiate the 3 ring release. As it released and he began to weight the letdown tape he heard a crack and began to drop. He bounced back up slightly “like a spring” before feeling a snap and falling 30 feet.
As he fell from the tree, the jumper remembered thinking to put his feet together in preparation to do a Parachute Landing Fall (PLF); evidence of the ingrained training. When he hit the ground a log sabotaged the PLF attempt and he found himself on all fours with blood dripping through his face mask onto his arm. His rookie trainer was there in an instant gently removing his helmet to find the source of the blood and immediately shouted for help. To her he looked to be in a fair amount of pain but seemed to be downplaying it. She remembers hearing him say “Just give me a bit to lie down and I will be fine.” Just behind her was the EMT from the West Yellowstone load, deeply concerned about the injuries possible from the mechanism of injury (MOI). Given the impact, he asked the fallen jumper to lie down and began coordinating the removal of gear to expose potential injuries. Looking back up at the tree, the injured jumper was confused to see the parachute still hanging in the tree suspended in the branches and couldn’t quite work out how he fell but the parachute remained. As theEMT performed the head to toe assessment of the patient the only findings were a laceration to his lower lip and pain, 3 out of 10, on palpation of the lower back.
Within 30 minutes of being requested, a local air ambulance was off the ground in Bend headed toward Lily Lake to pick up the injured jumper. The team in dispatch continued pursuing contingency plans and checking each other on “things that have gone wrong in the past.” They confirmed HEAR (hospital emergency ambulance radio) frequencies so the firefighters on the ground could talk to the air ambulance, and continued to keep leadership informed of their progress. They even pursued the availability of air ambulances, hoist ships and air rescues from as far away as Kalispell, MT. All of them were determined to apply the lessons learned highlighted in previous Facilitated Learning Analysis documents.
The firefighters in the jump spot prepared for the arrival of the medivac helicopter. Jump equipment had been secured and tucked away in the trees. They had spent 30 to 40 minutes felling green trees and snags to improve the landing zone. The patient was packaged and waiting. Using their head lamps, they stood at the edges of the helispot indicating the landing area. The IWI IC stood in the middle of the meadow with a fusee to guide the helicopter in until it was about 100 feet off the ground. He then snuffed it out and moved out of the way. With no apparent hesitation the air ambulance pilot lit up the helispot, swept in and landed like “parking a car at the grocery store.” By 2131 the medivac ship had the patient loaded and was headed toward the hospital in Bend, OR where a hospital liaison from the local forest was already waiting.
The level of care the injured jumper received on scene and the coordination between the Lily Fire IWI IC and the Lily Fire IC, dispatch and the UAOs helped facilitate a quick extraction to definitive care. After four days in the hospital and surgery to repair broken vertebrae perilously close to his spinal cord, the injured jumper walked out of the hospital with rods and screws in his lower back. He expressed the doctors believe a full recovery is likely, but will take quite some time.
Comments later from the Medivac Pilot:
- Night operations into a forested clearing, “is about as challenging a thing as we do.”
- Had positive communications with ground personnel early. Without it we are not able to do night ops.
- Ground personnel were using headlamps to illuminate Landing Zone. Was able to see where they wanted me and then asked them to shut off lights as we got close so we could use Night Vision.
- We were able to put patient from existing packaging right into our ship.
Based on the evidence on scene, it was determined by smokejumper equipment subject matter experts that what most likely caused the smokejumper to fall out of the tree was a misrouting of the letdown tape while securing it to the parachute riser.
As described by the USFS Ram-Air Parachute Training Guide, the smokejumper performing a letdown will tie the letdown tape to the riser by threading the tape between the V formed on the tight riser (inside to outside), wrap the tape around the back of the riser, around the front of the riser, and thread back through the V from outside to inside, then tie off using three half hitches. However, if the smokejumper does not route the tape over the top of the main letdown line as the tape goes around the front of the riser, the knot looks correct, but does not adequately secure the smokejumper to the riser. When the smokejumper disconnects his/her harness from the riser, there is a potential for the letdown tape to slip from the riser, causing the smokejumper to fall.
Though the Ram-Air smokejumper letdown procedure has been in use for over 30 years (in the BLM and more recently in the FS), the first documented case of this error occurring happened earlier this year. It had hitherto not been understood that misrouting the tape in this way could result in a dangerous situation. When the potentially dangerous misroute was discovered by a smokejumper performing a proficiency letdown during refresher training, it was reported through the smokejumper Malfunction Abnormality Reporting System (MARS) database and distributed to all smokejumper bases, where it was discussed with all smokejumper personnel. A video illustrating the hazard was also produced by the base where the misrouting occurred and distributed to all other bases.
In light of this accident, it was quickly decided by the Forest Service Smokejumper Base Manager Council that the letdown procedure would remain in its current form, but that all smokejumpers will now verbalize routing the tape over the top of the main letdown line as part of the 5 point check that smokejumpers verbalize before releasing their harness from the risers.