• Doug Fir 777

What Are The Known Fatal YH Fire Weather Factors Explaining What Led to the GMHS Fatalities? Pt. 2

Restating the post title beyond the limited Wix title allowance: What Are The Known Fatal Yarnell Hill Fire Weather Factors Explaining What Led Up To The June 30, 2013, GMHS Fatalities? Part 2

Author Fred J. Schoeffler and other contributing authors


Views expressed to "the public at large” and "of public concern"

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Abbreviations used: Wildland Firefighters (WFs) - Firefighters (FFs).


The well-known saying “Red sky in the morning, sailor take warning. Red sky at night sailor’s delight” comes from his Bible verse: "and in the morning, ‘It will be foul weather today, for the sky is red and threatening.’" Matthew 16: 3 (NKJV)

Do you think this saying may have been followed by the GMHS on the YH Fire? “But who wants to be foretold the weather? It is bad enough when it comes, without our having the misery of knowing about it beforehand.”

Jerome K. Jerome, Three Men in a Boat

How about this one? Indeed, this one also may have applied to the GMHS on the YH Fire and other WF and FF fatality fires, ey? "It is known that wildfires behave unpredictably - this is fundamental - but it is my experience that humans in the presence of wildfire are also likely to behave in aberrant and unpredictable ways." Controversial Australian cartoonist, writer, painter, philosopher, and poet Michael Leunig

"The wind blows where it wishes, and you hear the sound of it, but cannot tell where it comes from and where it goes. ..." John 3:8 (NKJV)


This Part 2 post is where the dubious September 2013 YH Fire SAIT-SAIR discussion takes place. The Arizona Department of Occupational Safety (ADOSH) contracted report by the Wildland Fire Associates and ADOSH citations report will be Part 3 due to the voluminous content thus far. The 2013 Wildfire Today link is once again utilized. First off, within the SAIT-SAIR the words "weather" generated 101 hits, "wind" generated 133 hits, "outflows" generated 5 hits, and "gust fronts" generated 2 hits, with CTRL-F searches. Within the ADOSH report, the word "weather" generated 64 hits; the word "wind" generated 62 hits, and the word "outflow" generated 14 hits. In Part 1. this author focused on only key excerpts relative to the title, however, in Part 2. this author found it necessary to branch out further, detailed in the next paragraph.

It is important to shed light on their alleged GMHS mismanagement of deviations and the fatal decisions that followed. At first sight, the contrast is farfetched, but once the picture is painted there are similarities that make it useful related to the June 30, 2013, YH Fire weather that needs to be addressed. It demonstrates the impact of their point of no return and covers the SAIT-SAIR fuels, weather, topography, fire behavior, the amazingly accurate, useful, and verified (RiP) Doug Campbell Prediction System (CPS) to "Learn from the Past, Predict the Future" while dealing with the conventional wisdom of the "Alignment of Forces" ("The three forces usually associated with fire behavior are Weather, Topography and Fuel, AKA the fire triangle") should also include the causal, human factors, because the September 2013 SAIT-SAIR deception with their bogus predetermined conclusion mindset. You will find that they boldly and falsely state that the SAIT-SAIR is a "Factual and Management Report" per the Delegation of Authority included below. This author's comments will be in this format enclosed within [Bold black brackets and italicized texts - This author will often provide corrective and / or explanatory text as well.] Abbreviations will be utilized as much as possible to save space.

Pay close attention to the SAIT-SAIR language and logic and reasoning regarding the GMHS being initially briefed and informed about the fire weather forecast and their decisions, actions, inactions, and reactions progressively throughout June 30, 2013, as they were alerted visually as well as through radio transmissions about the weather changing. And to the fact that this fire weather was also increasing the fire behavior; and especially to the fact of numerous instances of the SAIT-SAIR admitting that the GMHS failed to follow, recognize, and acknowledge several of the Fire Orders and recognize and then mitigate several of the Watch Out Situations. (Figure 1.) All emphasis is added unless otherwise noted.

First off, we firmly believe in The Constitutional principles of the First Amendment regarding freedom of speech and of the press as we venture into the fatal YH Fire and GMHS wildland fire realm. It’s a journalist’s job to speak truth to power, question convention, and dig deeper so as to prevent obfuscation by those in control of our various systems, whether they be government or private industry. However, there should be a firm line between challenging power through journalism and merely writing something about those in power for what's known as "just for the sake of it.

In the era of the post-YH Fire and GMHS debacle, it’s noisy out there with all manner of fairy tale blather; "hindering one's healing," and accusations of "speaking ill of the dead," and "making the ultimate sacrifice," and how they “willingly gave their lives.” Their lives were taken from them! And so, just as journalists should pursue stories that peel back veils and expose the truth, they should also take seriously the huge responsibility of separating the signal from the noise, the truth from the lies. Thus, the YH Fire and GMHS debacle - the biggest cover-up, lie, and whitewash in wildland fire history!


In case you missed it, included in Part 1 - But first the basics - again. Because this YHFR post concerns wildland fire weather, it is prudent to begin with the recognized and accepted Rules of Engagement ("10 & 18") principles for Entrapment Avoidance that specifically relates to fire weather for those WF, FF, as well as non-WF and non-FF readers alike.


The first Fire Order states 1. Keep informed on fire weather conditions and forecasts.

The Watch Out Situations as guidelines dealing specifically with fire weather state:

4. Unfamiliar with weather and local factors influencing fire behavior.

14. Weather becoming hotter and drier.

15. Wind increases and/or changes direction.

Because Fire Weather determines fire behavior, in reality, from a WF perspective, it is safe to say that all of the other Watch Out Situations are affected in one way or another by fire weather during firefighting and aircraft operations. Yes, the fire weather needs to be assessed even when taking a nap near the fireline (#18). Ask any of the former GMHS that were on the 2012 Holloway Fire (NV-BLM) about this particular one. In a 2012 or 2013 Prescott FD GMHS Public Record regarding a Squad Boss interview, the lead question was about a good leadership example; the 2012 “Nevada Fire” was mentioned where several Fire Orders were violated and several Watch Outs were ignored resulting in them having to ‘quickly fire out around ourselves and our buggies and everything turned out alright.’ And it was mentioned again in an AZ Wildfire Academy S-131 Advanced FF-Squad Boss class discussion on Leadership and Human Factors. A former 2011-2013 GMHS on the same fire stated that this happened TWICE. They referred to it as the “Nevada Fire” in PFD Public Records. Moreover, go to this 2013 Vimeo video by Colby Drake – “we saved the GMHS buggies from burning up” (2:40 to 3:25 timeframe). When the helmet cam video pans to the left, in the upper left of the frame, freeze-framing the video will reveal a black hardhat GMHS running down the handline toward their Crew Carriers. The second time someone else "saved" the GMHS Crew Carriers.

Human Factors will also be addressed, mainly in the Human Factor Barriers to Situation Awareness, Hazardous Attitudes section (pp. x-xi) that are addressed in the NWCG IRP (2022 edition), which has remained constant over the years. (See also USFS Matt Holmstrom's excellent paper titled: Common Denominators and Human Topography IAWF Feb. 2016)

Hazardous Attitudes

Invulnerable – That can’t happen to us

Anti-authority – Disregard of the team effort

Impulsive – Do something even if it’s wrong

Macho – Trying to impress or prove something

Complacent – Just another routine fire

Resigned – We can’t make a difference

Group Think – Afraid to speak up or disagree

These principles have remained constant since the IRPG's inception in 1999 and are updated every few years thereafter. You will readily notice several of these Hazardous Attitudes that applied to the GMHS on June 30, 2013, and even before the YH Fire and GMHS debacle to those who worked with them and those who have done their diligent research. This is an NWCG Fire Weather Subcommittee Glossary of Terms link that may be useful throughout this post, especially for non-WFs and non-FFs. Moving on ...


Figure 1. Snippet of National Wildfire Coordinating Group (NWCG) Incident Response Pocket Guide (IRPG) back cover with Fire Orders and Watch Out Situations Source: NWCG

Figure 2. Snippet of USFS "5100-16" file designation Fire Orders shield circa 1977 (4/77) Fire Order No. 4 mentions only Escape Routes without Safety Zones Source: National Museum of Forest Service History website


The most practical decision-making is not making better choices, it's learning to deal with uncertainty. The most common thing holding people back from the right answer is holding on to your previous beliefs. Instead of instinctively rejecting new information, take in what comes your way through a system of evaluating probabilities.

Farnam Street, Predicting the Future with Bayes’ Theorem, Episode #37


Notwithstanding the alleged "official" version of the June 30, 2013, YH Fire and GMHS debacle - whether or not we all doubted its veracity and then examined it experientially, investigatively, intuitively, logically, or even scientifically - we all kind of know what happened on June 30, 2013. This post will add to that ongoing research and evidence and hopefully answer some of those nagging, elusive why questions. We begin with the alleged utterly disingenuous and dishonest "official" SAIT-SAIR and the Executive Summary version and proceed from there, preceded by a caveat below.


[Continuing on with the YHFR post, you will notice numerous SAIT-SAIR contradictions to their "no-blame, no-fault" predetermined conclusion of doing everything right, such as these - "They would lose sight of the fire quickly as they descended toward the Ranch. However, they would see the smoke and keep some idea what the fire is doing." Course of Action B1: Descend here; move toward the Ranch through the box canyon (p. 38) and "They could no longer see the fire, including its direction and rate of spread."

o They lost the ability to feel or see wind changes"

o They had a limited view of the smoke column, a lagging indicator of fire location and fire behavior. ..." (Key Action C: The Granite Mountain IHC’s shelter deployment around 1642 p. 40) [These direct conclusory statements clearly and unequivocally contradict their dubious conclusion]


Executive Summary

"Nineteen firefighters died on the Yarnell Hill [YH] Fire in central Arizona on June 30, 2013, after deploying fire shelters. They were members of the [GMHS], hosted by the Prescott Fire Department [Prescott FD or PFD]. One crewmember was separated from the crew earlier that day and was not at the deployment site."

(Executive Summary p. 1)


“Early on June 30, members of the Type 2 IMT began arriving. In a briefing at 0700, the incoming [GMHS] Superintendent accepted the role of Division Alpha Supervisor. His assignment was to establish an anchor point at the heel of the fire with the [GMHS]. The Type 2 IMT assumed command, an action formally announced by radio at 1022.”

“For most of the day, the fire spread to the northeast, threatening structures in Model Creek and Peeples Valley. Around 1550, the wind shifted and the fire started pushing aggressively to the southeast, toward Yarnell. Fire resources shifted to resident evacuation and structure protection in town. Only the [GMHS] remained out on the ridge, on the southwest perimeter of the fire. Personnel who communicated with the [GMHS] knew the crew was in the black at that time and assumed they would stay there. No one realized that the crew left the black and headed southeast, sometime after 1604. At 1630, thunderstorm outflows reached the southern perimeter of the fire. Winds increased substantially; the fire turned south and overran the [GMHS] at about 1642.” (SAIT-SAIR p. 1)


"When it is evening, you say, 'It will be fair weather, for the sky is red.' "And in the morning, 'There will be a storm today, for the sky is red and threatening.' Do you know how to discern the appearance of the sky, but cannot discern the signs of the times? " Matthew 16:2-3 (NKJV)

* * * * *

"There is a gap of over 30 minutes in the information available for the [GMHS]. [See the Firehouse article (6-1-18) by alleged lead “investigator” Brad Mayhew article titled: “Learning from Yarnell Hill - Brad Mayhew offers training exercises for developing yourself and your crew for the future in the hopes of preventing another tragedy like the Yarnell Hill Fire that killed 19 hotshots.” With several comments by this author (dougfir777 and fschoeff) and one alleged BWS regarding the also alleged, self-proclaimed "Historical Fiction" ... "author John Maclean and Holly Neill keynote speakers at the Southern California Foresters and Fire Wardens (SCFFW) conference in May 2018 ("Yarnell Hill 5 Years Later")." This is blatantly false as there are numerous pieces of evidence of EM and GMHS recordings - below is a Snippet of one of many detractors; this one from Rock Steady, a very credible WF source (insert) posted on Wildfire Today on January 20, 2014, justifiably casted credible doubt and rightly asserting incompetence of the SAIT as well as PFD Wildland BC Willis.]


[Continuing with the SAIT-SAIR.] "From 1604 until 1637, the Team cannot verify communications from the crew, and we have almost no direct information for them. There is much that cannot be known about the crew’s decisions and actions prior to their entrapment and fire shelter deployment at around 1642."

"It is known that the [GMHS] left the black sometime after 1604 and traveled through an unburned area toward a safety zone at the Boulder Springs Ranch [BSR]. Thunderstorm outflows changed the intensity and direction of fire spread, and the rapidly advancing fire eliminated the crew’s options of reaching the safety zone or returning to the canyon rim. They had less than two minutes to improve a deployment site. They were deploying fire shelters when the fire overtook them. Temperatures exceeded 2000°F, and the deployment site was not survivable. The nineteen crewmembers were found approximately one mile south-southeast of their last known location, approximately 600 yards west of the Ranch." (SAIT-SAIR p. 2)

* * * * *

"The State of Arizona convened a Serious Accident Investigation Team [SAIT]. A delegation of authority letter, signed by the State Forester on July 3, 2013, charged the Team with reviewing and reporting on the circumstances leading to entrapment of the [GMHS]. The [SAIT] used a variety of data sources and methods to reconstruct events and analyze them. In deliberations, the [SAIT] drew from their knowledge of wildland fire operations and culture, as well as the perspectives of Subject Matter Experts [SMEs]. Through these processes, the [SAIT] generated the following conclusions:

The [GMHS] was a fully qualified, staffed, and trained hotshot crew. They were current with the required training [this means they would be required to know all of the Fire Orders and all of the Watch Outs] and met work/rest guidelines [See this IM YH Fire article and comments which also indicate why third-year GMHS Crewmember McDid-Not [Brendan McDonough] was the alleged "Lookout" that fateful day because he was allegedly sick. ... "After years of delay, the [GMHS] autopsy records are released" (Investigative MEDIA (IM) - December 9, 2015 - "Neither the [SAIT] nor the wrongful death inquiry by the ADOSH examined what the men were doing the night before they were sent to Yarnell on what was supposed to be their first of two days off after working 28 of the previous 30 days including 26 days on fires and had just come off a 12-hour shift.]"

[From the December 9, 2013, IM article] "One of the most potentially significant, but easily misunderstood, findings in the toxicology reports is the presence of alcohol in the blood of 13 of the 19 Granite Mountain Hotshots ranging from .01 to .09 percent. A person is legally drunk in Arizona at .08%. Another hotshot had several drugs of abuse in his blood, but no alcohol. ... Published reports state at least three hotshots were drinking in a local Prescott bar on the evening of June 29. These included Zuppiger, Christopher MacKenzie and the crew’s sole survivor, Brendan McDonough"

[Consider this from the December 9, 2013, IM article - "The hotshots were drinking “at the Whiskey Row Pub, a dive in Prescott’s historic downtown,” according to 2013 story in Outside Magazine. “When the hotshots came to drink in groups, as they often did on rare days off, bartender Jeff Bunch gave them a discount. His son was a former crew member.”]. The crew followed all standards and guidelines as stated in the Standards for Interagency Hotshot Crew Operations and the Arizona State Forestry Division’s [AZ SF] Standard Operational Guideline 804." [and for a third time, this means they would be required to know the Fire Orders and Watch Outs and much more, and it supports the SAIT-SAIT "predetermined conclusion." However, the nagging question persists – how was it possible for 19 PFD FFs to do everything right, and yet they all die in one fell swoop?]

"• The Yarnell Hill area had not experienced wildfire in over 45 years. It was primed to burn because of extreme drought, decadent chaparral, and above average cured grass loadings.

"• Although Yavapai County had a Community Wildfire Protection Plan, many structures were not defendable by firefighters responding to the ]YH Fire]. The fire destroyed over one hundred structures.

"• Radio communications were challenging throughout the incident. Some radios were not programmed with appropriate tone guards. Crews identified the problem, engaged in troubleshooting, and developed workarounds so they could communicate using their radios. Radio traffic was heavy during critical times on the fire.

"• The fire’s complexity increased in a very short time, challenging all firefighting resources to keep pace with the rapidly expanding incident.


"• The [GMHS] had been watching the active fire burn away from their position all day but their observations did not lead them to anticipate the approaching outflow boundary or the accompanying significant fire behavior changes. These changes included a doubling of fire intensity and flame lengths, a second 90-degree directional change, and a dramatically accelerated rate of spread. [likely Fire Orders No. 1, 2, 3, 6, and 10 and Watch Out Nos. 4, 11, 14, and 15].

"• ]The [GMHS] left the lunch spot and traveled southeast on the two-track road near the ridge top. Then, they [left the safe black and] descended [into the unburned green fuels] from the two-track road and took the most direct route towards [BSR]. The Team believes the crew was attempting to reposition so they could reengage. [likely Fire Order Nos. 1, 2, 3, 10 and Watch Out Nos. 4, and 11],

"• The [GMHS] did not perceive excessive risk in repositioning to [BSR] [and there are indications of Bad Decisions With Good Outcomes and the Normalization of Deviance posted in AHFE papers in Part 1.].

"• The Team found no indication that the [GMHS] doubted the black was a valid safety zone, or that they moved towards the [BSR] because they feared for their safety if they stayed in the black. [supporting the SAIT-SAIR predetermined "conclusion" of no wrongdoing]

"• Although much communication occurred among crews throughout the day, few people understood [GMHS’s] intentions, movements, and location, once they left the black. [this was a common tactic of GMHS Supt. Marsh according to PFD FFs that "filled in" with the GMHS] The Team believes this is due to brief, informal, and vague radio transmissions and talkarounds that can occur during wildland fire communications. [supporting the SAIT-SAIR predetermined "conclusion" of no wrongdoing] Based on radio conversations, Operations and other resources had concluded the [GMHS] was located in the black, near the ridge top where they had started that morning. This resulted in confusion about the [GMHS’s] actual location at the time of search and rescue." (SAIT-SAIR p. 3)

"In retrospect, the importance of the 1526 weather update is clear. However, the update appears to have carried less relevance in the crew’s decision-making process, perhaps due to the wind shift (starting at about 1550) that preceded the outflow boundary, or perhaps because of the time it took the outflow boundary to reach the south end of the fire (at 1630). It is possible they may have interpreted the early wind shift as the anticipated wind event." (SAIT-SAIR - Executive Summary p. 3) [Supporting the SAIT-SAIR predetermined "conclusion" of no wrongdoing]


[And the most blatant statement of all and the linchpin to the "conclusion first" format follows below]

"The judgments and decisions of the incident management organizations managing this fire were reasonable. Firefighters performed within their scope of duty, as defined by their respective organizations. The Team found no indication of negligence, reckless actions, or violations of policy or protocol." (SAIT-SAIR pp. 3-4)

[In other words, how is it possible for the GMHS to do everything right yet 19 Prescott FD FFs died in one fell swoop? That is impossible! See ourEpic Human Failure on June 30, 2013"( ]In other words, how is it possible for the GMHS to do everything right yet 19 Prescott FD FFs died in one fell swoop? That is impossible! See our February 13, 2022, YHFR post titled: "How was it possible to do everything right and yet 19 Prescott Fire Dept. Firefighters died in one fell swoop on June 30, 2013?" and our 2018 AHFE paper titled "Epic Human Failure on June 30, 2013"]


"The judgments and decisions of the incident management organizations managing this fire were reasonable. Firefighters performed within their scope of duty, as defined by their respective organizations.

The Team [SAIT] found no indication of negligence, reckless actions, or violations of policy or protocol."



"This report has two parts. Part One includes the fact-based Narrative of the incident and offers the Team’s Analysis, Conclusions, and Recommendations. ["fact-based Narrative of the incident"? Are you kidding? This is clearly a fairy tale for the Naysayers, Deniers, and YH Fire and GMHS debacle Kool-Aid Drinkers!] Part Two"], the Discussion section, is meant to prompt discussion and facilitate learning. It explores multiples (sic) concepts and perspectives, in order to support the broader community seeking to make sense of the accident and to improve safety and resilience. Appendices provide technical details and other supplemental information." (SAIT-SAIR p. 4)

"The Investigation Process

Following the tragic loss of 19 lives on the [YH] Fire, the State of Arizona convened a ]SAIT]. A delegation of authority letter, signed by the State Forester on July 3, 2013, charged the Team with reviewing and reporting on the circumstances leading to entrapment of the [GMHS].

"This delegation is to perform the serious accident review of the Yarnell Hill Fire with the final objective of providing a factual and management report for accident prevention.

"Your duties include but are not limited to:


"3. Coordinating information exchange between team members, local law enforcement, coroner’s office, and others.

Signed by: "Scott Hunt, AZ State Forester; Jim Karels, Team Leader SAIT; and Mike Dudley, Deputy Team Leader SAIT”

[Consider now the somewhat blurry Snippet (Figure 3. below) of the July 3, 2013, AZ State Forestry (ASF) "Delegation of Authority" letter authorizing a SAIT, listed as Appendix G (page 112). Indeed, it contains deceptive and disingenuous language including a reference to provide a "factual ... report"]


Figure 3. Snippet of the AZ State Forestry Delegation of Authority Source: SAIT-SAIR

[What serious questions do you have regarding the veracity of this June 30, 2013, GMHS Deployment Zone SAIT-SAIR Figure 8. map image on page 88? Have you seen or heard of anything to raise any reasonable doubts? Did they really all deploy fire shelters together and die together?]

Figure 4. Snippet of the SAIT-SAIR Appendix C - PPE. Body positions at the deployment site. Figure 8. on page 88. Source: SAIT-SAIR


"The [SAIT] included representatives from local (Missoula Fire Department, Kern County Fire Department, Boise Fire Department), State (Florida), and Federal (US Forest Service, National Weather Service) governments, as well as independent experts from across the country. Appendix H includes a list of Team members." (SAIT-SAIR p. 5)

"Approach and Philosophy

"The primary goal of this report is to facilitate learning from this tragedy, in order to reduce the likelihood of future accidents. [This is a most surprising, and at the same time, accurate and correct statement by the SAIT because we are unable to prevent fatalities in any and all work groups; all we can do is reduce them based on "complete lessons learned"] To this end, the [SAIT] retained some of the most effective techniques of past investigations while integrating current theory and practices. The intent of this blending is to offer to the wildland fire community the highest-quality learning product possible, in a timely manner." [The SAIT "retained some of the most effective techniques of past investigations while integrating current theory and practices which included first establishing the "conclusion" they were directed to use and then supporting it with their alleged "facts." The current theory includes the FLA, CRaP, Learning Review, and the like concluding "it was just an accident, one of those things that happens, no blame, no fault, just "tell us your story." while engaging in Group Interviews, often taking years to achieve "final approval" by the Agency Administrators at the highest levels.]. The intent of this blending is to offer to the wildland fire community the highest-quality learning product possible, in a timely manner." (SAIT-SAIR p. 5) [This is better known as "incomplete lessons learned" and here it is nine years later and we are still learning new facts and truths and more on a regular basis. It must be kinda frustrating for "historical fiction" author Mr. John MacLean, having to continually wait on us to do his "investigation" for his thankfully infernally delayed or canceled book].


"This report does not identify causes in the traditional sense of pointing out errors, mistakes, and violations but approaches the accident from the perspective that risk is inherent in firefighting. Leaders are responsible for guiding firefighters in consideration of the tradeoffs between safety, risk management, and other organizational goals. In this report, the [SAIT] tries to minimize the common human trait of hindsight bias, which is often associated with traditional accident reviews and investigations." (see Hindsight Bias inset below) (SAIT-SAIR . p. 5)

"The [SAIT] based its approach on the philosophy that firefighters are expected and empowered to be resourceful and decisive, to exercise initiative and accept responsibility, and to use their training, experience and judgment in their decision-making. The wildland fire community uses a doctrine approach to fire suppression, which requires the use of judgment. An individual’s judgment in a given situation depends upon their unique training and experiences. The 10 Standard Firefighting Orders and 18 Watch Out Situations (10 and 18) are the foundation of training in fire suppression operations, but they require judgment in application. These principles, as stated below, outline the Team’s perspective regarding the use and consideration of the 10 and 18 in this report: [Based on these statements and the machinations of the SAIT-SAIR predetermined "conclusion" then the SAIT would have intentionally used this logic and verbiage to support these statements]


[Consider this photo series (below) on June 30, 2013, from 1504 (3:04 PM) in the upper left to the lower right at 1645 (4:45 PM) as the smoke columns noticeably progressively increase in size and intensity. At first blush, far from being "hindsight bias" these photos (especially the Figure 5a. 1629 and 1631 photos, respectively) clearly reveal that increasing fire behavior requires prudent and aware WFs and FFs to at least begin to reevaluate their decisions and actions, moving to or staying put in the safer ground.]

Figure 5. Snippet of YH Fire photo series in the Sesame Street and Shrine Corridor and Peebles Valley on the afternoon of June 30, 2013, revealing separate and distinct smoke columns, some suggesting firing operations, and certainly increasing fire behavior. Source: YHFR Gallery

Figure 5a. Snippet of June 30, 2013, fire behavior. Captions and explanatory text are embedded within photo images. The left 1629 photo was given to alleged "Lead Investigator" Brad Mayhew as evidence and yet never used in the SAIT-SAIR Source: YHFR Gallery

Figure 5b. SAIT-SAIR Figure 18. idealized image falsely indicating fire above and fire below Source: SAIT-SAIR

Figure 5c. 'Crossfade' video between ABC15 Helicopter Raw Video Footage clip number 18 (taken at the YH Fire on Sunday afternoon, June 30, 2013) and the equivalent 'Google Earth' imagery. The 'orange firelines' in 'Google Earth' views ONLY represent the FIRE that is CLEARLY VISIBLE in the video footage and does not represent the totality of the fire that was on the ground when the clip was shot. Source: YouTube, WTKTT

Figure 5d. Yarnell Hill Fire Photo Location Estimates Via LiveTexture. Source: Stephen Guerin

"Estimated locations of photos and videos during Yarnell Hill Fire 2013. The first image is mislabeled Air Attack. this video was an early technical test of the optimization algorithms for camera pose estimation. We are assembling a better documented collection for use in after action review."

InvestigativeMEDIA commenter on Guerin's YouTube Marti Reed "Wow, I just found this, thanks!!! I spent three years citizen-investigating this fire, working over all the photos and videos from it, with the crew on Investigative Media (see my videos). I finally gave up trying to shine the spotlight and ring the bell, since the Myth of the Yarnell Hill Fire completely overtook the Truth of the Yarnell Hill Fire."


The SAIT-SAIR would disingenuously allege on page 77 that] "[the fire] moved from along the base of the main ridge and reached the bottom of the middle bowl, one-half mile south-southeast of the origin, and split into two heads. The southern head entered an unnamed drainage that this report refers to as the “middle bowl.” The northern head continued burning along the base of the ridge. (Figure 18)" [This article with an interesting title: "why did granite mountain hotshots leave the black" from ( is also mysteriously nowhere to be found on the internet even with The Internet Archive Wayback Machine.]


"Principles of Suppression Operations

“'The primary means by which we implement command decisions and maintain unity of action is through the use of common principles of suppression operations. These principles guide our fundamental fire suppression practices, behaviors, and customs, and are mutually understood at every level of command.

They include Risk Management,

Standard Firefighting Orders and Watch Out Situations, LCES [Lookouts,

Communications, Escape Routes, and Safety Zones], and the Downhill Line Construction Checklist. These principles are fundamental to how we perform fire suppression operations and are intended to improve decision making and firefighter safety. They are not absolute rules. They require judgment in application.'” Footnote 1 - Interagency Standards for Fire and Fire Aviation Operations [Red Book], NFES 2724 (Boise, ID: Federal Fire and Aviation Task Group, Natl. Interagency Fire Center, Jan. 2013), p. 07-1. (SAIT-SAIR p. 6)


[This author and so many incredulous others question that mostly accurate Red Book statement above. Was this one of the supporting principles the SAIT utilized to come to their convoluted no-blame, no-fault predetermined conclusion? And the final two sentences are really somewhat ambiguous even though they sum up the fact that the GMHS were utilizing poor judgment that fatal day in June 2013. The ambiguity lies in the fact that the Fire Orders are considered rules and the Watch Out Situations are guidelines. This author alleges that the SAIT-SAIR intentionally and with malice blurred that distinction.]


"Report Structure (SAIT-SAIR p. 7) This report is in two parts, plus appendices.

"Part One includes the fact-based Narrative, the Analysis, Conclusions, and Recommendations. The primary purpose of the Analysis is to provide context for key action points associated with the entrapment and fire shelter deployment. This supports the Conclusions section, which represents the [SAIT's] impressions and conclusions about these

events. Recommendations presented to management are opportunities for improving safety. [This author contends that - with few exceptions - anything allegedly based on any SAIT-SAIR assertions, conclusions, or suggestions, is highly questionable, holding NO probative value].

"Part Two, the Learning Discussion section, explores multiple concepts and perspectives that may help readers to understand and learn from this accident. The intent is to prompt the wildland fire organization to think about and discuss how they can improve at the individual, team, and organizational levels, thereby improving both safety and resilience in their organizations." (SAIT-SAIR p. 7) [This author contends that a real problem arises with the fact that the SAIT-SAIR predetermined conclusion provides "incomplete lessons learned" and therefore would provide hollow to weak improvement at the "individual, team, and organizational levels" doubtfully improving either their safety or resilience. In reality, it would do more to weaken those organizational levels].


"The Yarnell Hill Fire occurred in west-central Arizona, west of the town of Yarnell along a north-south mountainous ridge with elevations of 4,500 to 6,000 feet. Within the fire area, the terrain varies from steep ridges to nearly flat valley bottoms with numerous rock outcroppings and boulder piles. The dominant vegetation type, chaparral brush, ranged in height

from one to ten feet and, in some places, was nearly impenetrable. The Yarnell Hill Fire area had not experienced wildland fire since 1966.

"Conditions leading up to the Yarnell Hill Fire consisted of very high to extreme fire danger and extreme drought during a transition to the Southwest’s summer monsoon season. During this seasonal transition,

temperatures are typically very hot. Relative humidity values remain low but fluctuate as storms become more numerous and cloud cover more prevalent. Winds are highly variable with the highest wind speeds

occurring during thunderstorms. These storms can generate strong downdrafts, micro-bursts, outflows, and gust fronts, all of which can affect fire behavior. (SAIT-SAIR p. 8)

"Part One: Factual & Management Report


"The purpose of this narrative is to help readers understand the events occurring around the [GMHS] on the day of the accident. It is impossible to construct a complete account of the crew’s movement and entrapment because they cannot give their perspectives." [On the contrary, the SAIT-SAIR is less than factual and it is - and would be - indeed very possible to determine the GMHS movement and eventual entrapment with at least four of their GPS Units that were kept in YCSO evidence for at least a year after the event and the investigation. And so YH Fire and GMHS debacle characteristically accurate when finally revealed by the YCSO - those key GPS memory cards were "mysteriously missing." Imagine that!]

[Please consider this July 16, 2020, YHFR post titled: "Why did it take seven years for the GMHS GPS Units to finally become public record? Why Brad Mayhew?"]

"Instead, the [SAIT] relied on others involved with the fire and with the crew, as well as on data gathered during the investigation, to reconstruct the most accurate account possible. [So then, when the SAIT claims that "It is impossible to construct a complete account of the crew’s movement and entrapment" you need to seriously question this and ask yourselves - how reliable, how trustworthy, how honest, how many YH Fire Kool-Aid Drinkers, Go-Along-To-Get-Along types, etc. had "the [SAIT] relied on [these] others involved with the fire and with the crew, as well as on data gathered during the investigation, to reconstruct the most accurate account possible" in order to come to the predetermined conclusion of no blame, no-fault, no wrongdoing?]

"Different individuals can perceive the same event differently. This account acknowledges interpretations may vary from one person to the next, and there can be apparent inconsistencies between individual perspectives. However, in most cases, the [SAIT] corroborated key details with two or more data sources. [SAIT] members also shared portions of the narrative with key interviewees to correct and clarify important details." [Do they mean "to correct and clarify important details" in order to come to the predetermined conclusion of no blame, no fault, no wrongdoing? ]

"The narrative is in present tense to help readers place themselves in the boots of the people involved. Instead of personal names, the Team uses Incident Command System (ICS) or other acronyms to protect the privacy of personnel involved in the incident (see Appendix F for fire terminology and acronyms). Parts of the narrative occasionally backtrack to capture a variety of perspectives and simultaneous events on different areas of the fire. (SAIT-SAIR p. 11) [This backtracking that the SAIT-SAIR refers to can be somewhat, to very confusing at times]


"Sunday, 30 June 2013

"At the 0700 briefing on June 30, ICT4 and others from the previous shift meet at the Yarnell Fire Station with incoming personnel including ICT2, two Operations Section Chiefs (OPS1 and OPS2), SPGS1, a fire behavior analyst (FBAN), YCSO deputies, and the [GMHS] Superintendent [Marsh]. The briefing covers strategy and tactics, the previous night’s spot weather forecast (SAIT-SAIR Figure 4), and radio frequencies. They review the area using Google Maps on an iPad, and they note Boulder Springs Ranch [BSR] as an excellent safety zone." (SAIT-SAIR p. 15)

Figure 6. Snippet of June 29, 2013, 2033 PM NWS Spot Fire Weather Forecast for the YH Fire at 1618 MST (SAIT-SAIR Figure 4. on p. 15) Source: SAIT-SAIR

Figure 7. Snippet of June 30, 2013, Boulder Springs Ranch (BSR) the alleged "bomb proof safety zone" prior to burning on June 3, 2013. Source: Joy A. Collura Gallery


[Continuing with the SAIT-SAIR.] "They establish the command channel setup and communications plan for the incident. As part of the leader’s intent, they also discuss strategies for the north side of the fire and for keeping the fire, now estimated at 300 to 500 acres, out of Yarnell by improving old roads, taking advantage of previous fuel mitigation work, and constructing some new dozer line to backfire if necessary. They lay out a strategy to establish an anchor on the south end. They also agree the [GMHS Supt.] will become Division Supervisor Alpha (DIVS A) and his Assistant [Supt. GMHS] Captain or GM Capt will run the crew. DIVS A’s assignment is to establish an anchor point at the heel of the fire, using direct or indirect tactics as appropriate." (SAIT-SAIR p. 15)


Figure 8. (left) June 30, 2013, 1347 (4:37 PM Yavapai County Morin dozer "improving old roads ... to backfire if necessary" in the Sesame and Shrine Corridor area. (right) June 30, 2013, 1349 (4:39 PM Morin dozer "improving old roads ... to backfire if necessary" in the Sesame and Shrine Corridor area Source: YHFR Gallery



"Fire activity increases throughout the morning as the weather gets warmer and drier. Fire personnel observe distinct cloud build-ups well to the north by late morning. One particular cell building to the north concerns OPS1 and he contacts DIVS A on the radio. He confirms that DIVS A can see it through the smoke; DIVS A says he will keep an eye on the cloud movement." (SAIT-SAIR p. 18)

"As the [GMHS] continues its burnout, DIVS A and Air Attack discuss options. Air Attack directs two SEAT drops at 1136 and 1145 directly onto the burnout. DIVS A is frustrated. This is not what he wanted but he has [GMHS] shift tactics and go direct along the fire’s edge." (SAIT-SAIR p. 18) [See also Joy A. Collura's photo below of this blundered incident and watch the video clip of the SEAT retardant drops as well].

Figure 9. Snippet of June 30, 2013, where Air Attack directed two SEAT drops at 1136 and 1145 directly onto the GMHS burnout. Source: Joy A. Collura

[Joy A. Collura asks this question in one of her blogs about the SEAT drops that was posted in the SAIT-SAIR: "Help me understand… how Rory Collins suppressed their fire operation and I saw the frustration over there in real time …"] (


"As the [GMHS] continues its burnout, DIVS A and Air Attack discuss options. Air Attack directs two SEAT drops at 1136 and 1145 directly onto the burnout. DIVS A is frustrated. This is not what he wanted but he has [GMHS] shift tactics and go direct along the fire’s edge." (SAIT-SAIR p. 18)

[Joy's video (link directly below) is well worth viewing of the early stages of the June 30, 2013, YH Fire burning and popping noises and a look at the 2-track road and the vegetation in the blundered or intentional SEAT retardant drop area. ( )]


[The SAIT-SAIR continues:] "At 1402, FBAN receives a call with a weather update from the NWS office in Flagstaff. The NWS informs him of thunderstorms east of the fire that may produce wind gusts of 35 to 45 mph out of the northeast. FBAN relays the update to OPS1 and OPS2 via radio on state tactical frequency 1 (Tac 1)." (SAIT-SAIR p. 22)

"At 1526, NWS-Flagstaff calls FBAN with a second weather update about expected thunderstorm outflow winds from the north-northeast with speeds between 40 and 50 mph. (SAIT-SAIR p. 22)

"This update does not meet the NWS criteria for a Red Flag Warning for this area. FBAN radios this second update to OPS1 and OPS2 on Tac 1. (SAIT-SAIR p. 22)


"OPS1 is listening on the radio to make sure everyone received the most recent weather announcement. At about 1550, he radios DIVS A directly to ask if he got the weather update and if he is “in a good spot.” DIVS A affirms that he received the update, and he tells OPS1 the winds are starting to get “squirrely” up on the ridge. He says he is working his way off the top and OPS1 closes by advising DIVS A to hunker and be safe. (SAIT-SAIR p. 22)

"Also, at about 1550, GM Lookout is taking weather observations when GM Capt calls him to relay the weather update. DIVS A hears the transmission and copies. GM Lookout copies and continues taking weather observations. He looks at the fire to the north and notes it is moving slowly toward his location. He scans back up to where the crew is working, to the thermometer, back to the crew, and then back to the fire. In that short time, the fire has started building and the wind is already beginning to shift. GM Lookout is not worried, but he recognizes it is time for him to move. He calls GM Capt and says the fire has hit his trigger point and he is moving towards the open area at the old grader. GM Capt calmly replies, 'Okay, cool.'" (SAIT-SAIR p. 23)


[Consider now our YHFR post Figure 10. of two SAIT-SAIR YH Fire and GMHS photos (Figure 8. and Figure 9. respectively) of GMHS viewing the fire below them around 1550 to 1604 according to the embedded captions]

Figure 10. Snippet of SAIT-SAIR Figure 8. (left) GMHS MacKenzie 1550 photo with fire pushed by a SW wind and Figure 10a. (right) Snippet of SAIT-SAIR Figure 10b. (right) GMHS Parker texted this 1604 photo of a GMHS with fire pushed by a Southwest wind. Source: SAIT-SAIR pp. 23 & 24 respectively


"[The SAIT-SAIR continues:] Earlier that day, the YCSO issues pre-evacuation notices to area residents. In Northern Yarnell and the Shrine area, SPGS1 has three trigger points for evacuation. The first [trigger point] is on a ridge one mile north of town. Resources in the area anticipate a one-hour window to evacuate the residents when the fire reaches this trigger point. SPGS1 establishes a closer, second trigger point for the firefighters themselves to start leaving the area. He has a third trigger point for making sure everyone is out. (SAIT-SAIR p. 24)

"A task force [Sun City West FD] with Structure Protection Group 1 is working in the area. They are cutting a piece of indirect line from the area near the youth camp on Shrine Road eastward to a boulder pile, expecting that they may need to burn off this line overnight. This piece of indirect line connects to the dozer line between Shrine Road and Sesame Street, which the Blue Ridge IHC have been prepping since about 1500."


[For clarification and edification, and to put things into perspective please consider this Snippet (below Figure 11a.) of a Google Earth idealized image, looking Northwest indicating the up-slope alignment of the Sesame Street To Shrine Fuel / Fire Break Corridor (upper center black horizontal arrows) to the parallel chimneys / chutes / washes (yellow pins and vertical curved black lines) leading up to the GMHS deployment zone and fatality site near Boulder Springs Ranch (BSR) / Helms (cleared area) located center-right.]

Figure 11. Google Earth image of indirect dozer line between Yarnell, the Sesame Street and Shrine Road Corridor, and the parallel twin chutes leading uphill to the eventual GMHS Deployment Zone and fatality site. Source: Collura, Google Earth

[For further clarification and edification, please consider a Snippet of a Google Earth enhanced image, looking Northwest indicating the up-slope alignment of the Sesame Street To Shrine Fuel / Fire Break Corridor (upper center black horizontal arrows) to the parallel chimneys / chutes / washes (vertical curved black lines) leading upslope like a slingshot directly to the GMHS Deployment Zone and Fatality Site near the Boulder Springs Ranch (BSR) / Helms (cleared area) located center-right.]

Figure 11a. Snippet of Google Earth idealized image, looking NW indicating up-slope alignment of the Sesame Street To Shrine Fuel / Fire Break Corridor (upper center black horizontal arrows) to the parallel chimneys / chutes / washes (vertical curved black lines) leading up to the GMHS deployment zone and fatality site. Boulder Springs Ranch (BSR) / Helms in the center-right. Source: Google Earth, Paint, and Collura's Yavapai County Records Request 7-9-14\Audio video recordings\Video Files; FA42 IMG_1584.MOV July 4, 2013, 2:34 pm

Figure 11b. Google Earth vertical profile of YH Fire Sesame Street and Shrine Corridor upslope virtual slingshot funneling winds and fire behavior aligned from right to left, NE↔SW, directly into the GMHS deployment zone and fatality site. (Not to scale) Juxtapose with Figure 11a. (above) for better clarity.Source: Google Earth

[The SAIT-SAIR continues:] "Between 1530 and 1545, winds pick up and gradually shift direction from the southwest to the west-northwest, and the fire becomes very active. There is some spotting, and heavy ash is falling onto fire personnel working in the youth camp area. By this time, the two-mile flanking fire looks more like a head fire and is starting to move southeasterly." (SAIT-SAIR p. 25)

Figure 11c. Snippet of Summary of afternoon wind shifts insert of June 30, 2013, YH Fire weather Source: SAIT-SAIR (p. 25)

[It is well worth viewing this YouTube link (below) to as many as eighty (80) informative and instructive YH Fire and GMHS videos by the consistently accurate and credible InvestigativeMEDIA avatar named WantsToKnowTheTruth (WTKTT) that provide further clarification and edification of fire perimeters, fire personnel, equipment locations, their movements, and much more utilizing Google Earth overlays and crossfades and crucial embedded metadata from various GMHS videos, camera images, and news coverage videos] (ABC15 Clip-18 Crossfade)]

Figure 12. GMHS MacKenzie (RiP) photo series from 3:51 PM to 3:55 PM revealing several GMHS in the black in their Safety Zone geared up as if they are ready to go even with increasing fire behavior based on increasing SW winds clearly visible down below them Source: AFS Dropbox


[Continuing with the SAIT-SAIR:] "The fire outperformed their expectations even with many knowledgeable people there, and their trigger points were not valid, not even “by one half,” given the push by the weather." (SAIT-SAIR p. 26)

* * * * *



"The wind blows where it wishes, and you hear the sound of it,

but cannot tell where it comes from and where it goes. ..."

John 3:8 (NKJV)


"During the [GMHS] movement and deployment, an outflow boundary moves southward toward the fire area and the atmosphere becomes more erratic ahead of this boundary. Even before the outflow boundary arrives, the wind direction shifts to west-northwest and the fire responds with stronger movement toward the east-southeast. The outflow boundary reaches the northern portion of the fire around 1618, having covered 13.5 miles in 50 minutes (16 mph). As it initially crosses into the fire area, several things occur: the smoke plume rises to over 31,500 feet; two fingers of concentrated smoke begin to develop from two main heads of fire moving southward; and southward fire rates of spread begin to quickly escalate. The boundary drives the fire southeast and south at increasing speeds with rapidly increasing intensity. Thunder rumbles and spritzes of rain or mist mixed with ash fall over portions of the fire area. The outflow boundary reaches the southern perimeter of the fire at 1630, and pushes the fire to the main ridgeline to the south and into Glen Ilah and Yarnell. By 1648, the smoke plume top grows to 40,000 feet mean sea level (MSL)." (SAIT-SAIR p. 29)

"Several fire resources, beginning with firefighters on the north end, notice the “spritzes” of rain. The mist reduces ASM2’s visibility as it mixes with ash on the windows. Thunder heard with the smattering of rain and a very short period of calm wind conditions cause several firefighters in Yarnell to think about the 1990 Dude Fire in Arizona and the six fatalities that occurred on that fire. (SAIT-SAIR p. 29) [The Sun City West Task Force Leader had recounted an earlier 2013 AZ Wildland Fire Academy lesson from the 1990 Dude Fire when former Prescott HS Asst. Supt. Tony Sciacca told of his prior experience with the deceptively subtle signal of the outflow winds on June 26, 1990, that forced the smoke down to the surface while it pooled at waist level "like something in a horror movie" with the spritzes of rain and then the violent downdrafts immediately following. This caused the fire behavior to violently increase in intensity and speed down Walk More Canyon in a horizontal roll vortices-like fashion. (East July 18, 2014)] >

"Key Action A: The Granite Mountain IHC’s movement to the southeast along the two-track road, sometime after 1604. (SAIT-SAIR p. 34)


"Prior to 1604, the Granite Mountain IHC likely knew or perceived the following:

"• A spot weather forecast generated the evening before, and given to the [GMHS] early on June 30, indicated a slight chance of showers and thunderstorms in the afternoon.

"• A weather update received shortly after 1402 advised of thunderstorms to the east that could produce winds of 35 to 45 mph out of the northeast. These winds never materialized; the crew could have perceived this as a false alarm.

"• FBAN provided a second weather update sometime after 1526 on State Tac 1. The radio transmission passed on a NWS weather update about an outflow boundary north of the fire that may produce north or northeast winds of 40 to 50 mph.

"• Over the radio, OPS1 asked DIVS A if he received the later weather update, and if they were in a good spot. DIVS A affirmed they received the update.

"• GM Capt relayed the update to GM Lookout around 1550, advising of possible wind direction shifts and thunderstorms.

"• The flanking fire in the area below the [GMHS] had started to become more active with west winds at 10 to 12 mph.

"• GM Lookout left his lookout spot in response to the fire crossing a defined trigger point. At about 1555, BR Supt picked up GM Lookout and contacted the [GMHS], who tells BR Supt they have “good eyes” and they are “in the black.” [This was an entirely unplanned event. BRHS Supt. Frisby saved the alleged GMHS "lookout" that day. Frisby stated that he had to argue with him to get in and get going.]


"• While scouting, DIVS A encountered two local residents, avid hikers who are familiar with the area. The hikers [Joy A. Collura and Sonny Gilligan] took a path down the two-track road along the ridge to the southeast toward the Boulder Springs Ranch. They discussed their route with DIVS A prior to leaving. (SAIT-SAIR p. 34)


[Mentioned in the SAIT-SAIR, consider now three photos (below) by Joy A. Collura of the GMHS, two of Supt. Marsh hiking up one of the mid-slope two-track mining roads, and the classic one of the GMHS in Figure 15.]

Figure 13. Snippet of GMHS Supt. Eric Marsh wearing a red hardhat, acting as the DIVS A, hiking up one of the old mining roads on June 30, 2013, at about 0830 AM to 0900 AM. Source: Collura

Figure 14. Snippet of a close-up photo of GMHS Supt. Eric Marsh wearing a red hardhat, acting as the DIVS A, hiking up one of the old mining roads on June 30, 2013, at about 0830 AM to 0900 AM. Neither photo is included in the SAIT-SAIR. Source: Collura


(SAIT-SAIR p. 34)

"At about 1555, BR Supt picked up GM Lookout and contacted the [GMHS], who tells BR Supt they have 'good eyes' and they are 'in the black.'”


Figure 15. Snippet of the SAIT-SAIR Figure 5. p. 17 of the GMHS hiking hung over up one of the old mining roads on the morning of June 30, 2013. Source: Collura Gallery


"Course of Action A1: Stay in the black

An active weather update called for north-northeast winds with gusts up to 50 mph. Fire spread direction was likely to change during the afternoon. The fire was actively running to the east-southeast, exhibiting extreme fire behavior, which exposes a very long flank. If the north wind materialized, it could drive the open flank south (i.e., the flank could turn into a head fire). [The fire has all along been “signaling its intentions.”]

The cold, black area adjacent to them was over 400 acres and extended over the lee side of the ridge.

• The [GMHS] and DIVS A were the only resources remaining on the fireline. the others had withdrawn to Yarnell.

The [GMHS's] original assignment to establish an anchor point and construct fireline was no longer valid based on fire movement, so there was no tactical reason to remain at this location."

Radio traffic indicated a distinct threat to the community of Yarnell so there was a tactical reason to move from this location.

• The threat to GM Lookout and the [GMHS] trucks had been mitigated by moving them to a safer location.

• Staying in the black required less arduous action" (SAIT-SAIR pp. 35-36)


"Course of Action A4: Move southeast along the two-track road toward the [BSR]

Clearest need for firefighting resources is in Yarnell, not near the black area.

• Moving to Yarnell provides the fastest opportunity to re-engage tactically.

Had not yet observed wind direction shift as described in most recent weather update–fire was still moving east-southeast, it had not started moving south.

The [BSR], identified as a “bomb proof safety zone,” is between them and Yarnell.

Fire still appeared to be moving away from them, or at worst, parallel.

There was a very rocky ridge between the fire and where they wanted to be. They could have perceived this as a natural barrier to fire movement.

• They perceived this southeast pathway as an escape route.

• If they take this route, it appeared they would still have alternate escape routes southwest over the ridge or back to the black the way they came.

While traveling along the ridge, they would have a comfortable view of the fire and could see it headed to the east-southeast; they could serve as their own lookouts." [But they obviously forgot about LCES and failed at being “their own lookouts."]Contradicting the SAIT-SAIR “conclusion” of no blame, no fault]