Create Corrective Action



S A F E N E T
Wildland Fire Safety & Health Reporting Network
Report unsafe situations in all wildland fire operations.

ID # 4WV3LLSAFE


REPORTED BY

Name : (Optional)



Phone : (Optional)


EMail : (Optional)



Date Reported :

05/18/2001

Agency/Organization :

USFS




State Agency :





Other Agency :




EVENT

Event Date :

03/23/2001


Local Time :

11:00 am

Incident Name :

SILVERMOON #2


Incident Number :


State :

OR




Jurisdiction :

USFS


Local Unit :

cottage grove


Incident Type :


Incident Activity :


Stage of Incident :

Prescribed


Support


Initial Attack


Position Title :

Engine Operator

Task :

Pre Treating

Management Level :

1

Resources Involved :

Model 80 Engine
SAFETY/HEALTH ISSUE
Brief description of concern/condition or potential issue:


We were directed to pretreat some small areas of reprod which were adjacent to a unit we were planning to burn that day. We used 2 loads of water and were preparing to start on a third. I parked the engine at the side of the road. Then moved the gearshift to neutral and set the emergency brake and got out of the cab. On my way back to get the wheel chock I stopped to extend a 50 ft. section of hose w/nozzle and told my crewperson to engage the PTO. Shortly after doing this the engine proceeded to roll forward. The truck went off the bank and landed on its side in a cluster of small trees.
Fortunately no one was injured. The engine was not totaled and is being repaired.
The important message here is that although the selector had been moved to neutral position THE VEHICLE WAS STILL IN 6TH GEAR! Engaging the PTO pump caused the vehicle to move under its own power. It is important that all of our operators of fire engines and crew buggies with the Allison 6 speed transmission hear about this accident. I would strongly urge them to make sure the vehicle is actually in neutral before leaving the driver’s seat, and by all means get a wheel chock under the tire before doing anything else.
CONTRIBUTING FACTORS

Contributing Factors :

Equipment

Human Factors :


Other Factors :



Beware of the Allison Automatic Transmission, the selector may say you’re in neutral but in fact you may actually be in 6th gear! This has been proven by our forest shop so take great care operating any vehicle with the 6-speed Allison Automatic Transmission.
ENVIRONMENT
Describe: (Weather, Fire Behavior, Fuels, Terrain, Footing, Road Conditions, etc.)


Good weather on dry Forest Service roads. The engine was facing downhill.
NARRATIVE
Describe in detail what happened including the concern or potential issue, the environment (weather, terrain, fire behavior, etc), and the resulting safety/health issue.


See above.
SITUATION REVIEW
Reporting Individual: please list anything that, if changed, would prevent this safety issue in the future:


Some form of confirmation that the gear selected is the gear you are actually in! It has been suggested that a glow light of some kind be mounted in the drivers cab as well as the pump control panel confirming that you are in neutral.
SUGGESTED CORRECTIVE ACTION
Reporting Individual : Please list anything that, if changed, would prevent this safety issue in the future.


CORRECTIVE ACTION
Please document how you tried to resolve the problem and list anything that, if changed, would prevent this safety issue in the future.


Get the wheel chocked before doing anything else, in this case it is unclear that would have prevented this accident since the truck was facing downhill and under its own power.
I would suggest remaining in the truck until another crewmember gets the wheels chocked, at least until some other mitigating solution could be found.

SAFENET - 4WV3LLSAFE
. . Supplemental Corrective Action - 4XVMXPSAFE

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