Combined Impact

During the spring and summer of 1999, I experimented with a training approach to enhance existing annual safety refresher training using the Lessons Learned course materials, while simultaneously raising the awareness of the Firefighter Safety Awareness Study and its findings at the lowest, field levels of the client organizations.

I was approached to provide annual safety refresher training for employees of Grand Teton National Park and the Bridger-Teton National Forest. In both instances, the Fire Management Officers were interested in a new and interesting approach to required, annual training and wanted to use the just- released Lessons Learned course materials.

I have been a part of TriData's project consulting team on the Firefighter Safety Awareness Study for four years. As such, I know that awareness, understanding and appreciation of the study and its recommendations are not widespread at the lowest, field levels of the agencies who commissioned the study. 18 months following the release of the final report it is common to find both primary and collateral duty firefighters who have little or no knowledge of the study or its implications.

Though one should expect gradual implementation and transition in large, decentralized bureaucracies such as these, creating an understanding of the study's recommendations and implications at the "pointy end" of the sponsor agencies represents a critically important priority.

Understanding that this would be the case, I recognized an opportunity to accomplish several desirable aims. We could simultaneously provide effective safety training, raise awareness of the study's findings, while teaching people to employ a risk management process. Further, we would do so by employing a state-of-the-art training package, studying case studies of fatality fires using a lessons learned approach.

The situation presented me with an opportunity, to introduce the Firefighter Safety Awareness Study to more than 100 participants in the training sessions I conducted. I discussed the value of the final report to operational/field level managers and supervisors, and provided information on how the participants might obtain the report either in hard copy or on the Internet. 10

However, my primary objective was to provide effective safety refresher training for the participating employees. Some participants had primary fire control responsibilities, but many were collateral duty firefighters, with a wide range of experience. Nearly all had attended annual refresher training before, some for many years, and most were weary of a standardized training package that had been in use for several years.

The NWCG's Lessons Learned: Fatality Fires Case Studies course provides an excellent opportunity to reinforce key findings of the Wildland Firefighter Safety Awareness Study. To suit the nature and need of my target audiences, I chose to focus on improving situational awareness, using a risk management approach, improving communications, the dangers of command transition and fatigue.

One can better understand the importance of each of these topics by examining the study report's analysis of their contribution to firefighter safety problems.

Situational Awareness:

According to the study report, "Situational Awareness is one of the most difficult skills to master and is a weakness in the fire community. The report goes on to state that "The culture must change so that people are observing, thinking, and discussing the situation constantly."11

Situational awareness is a combination attitudes, previously learned knowledge and new information gained from the work environment that enables the firefighter or tactical decision maker to gather the information they need to make good decisions that keep their people and themselves out of harm's way. The situationally aware firefighter anticipates fire behavior and other physical and organizational challenges to their safety, clearly communicates their assessment and calibrates their team's understanding of the situation. Situational Awareness represents one of five fundamental steps in the risk management process which forms the cornerstone of the Lessons Learned courseware.

Risk Management Approach:

One of the study's key findings is that fire safety practices should be driven by a systematic risk assessment. Operations that are guided by a risk assessment require an organizational culture of wildland firefighting that flows around a core philosophy of risk management. That culture is not yet well developed in the federal agencies that fight fire in the United States.12

As previously noted, a five-step risk management process provides the foundation of the Fatality Fire Case Studies course. The process provides firefighters and tactical decision makers with a decision making aid for identifying and mitigating hazards during fireline operations. Additionally, it provides an important framework within which firefighters can better apply existing tactical safety guidelines.


According to TriData, "Resolving the agencies' communication issues will require a comprehensive approach that includes improvements in communication "soft skills;" establishment of sanctioned communication processes, procedures, and protocols; radio system capacity improvements; adequate distribution of radios; and diligent accountability for change." Evidence shows that organizations employing skills and protocols such as those outlined in the study report achieve "organizational resiliency" in emergencies through clear and fail-safe communication.13 The impacts of communication breakdown and the need for organizational resiliency through clear and fail-safe communication is well borne-out by a number of the case studies presented in the Lessons Learned package.

Command Transition:

Expert firefighters interviewed during the study recognize initial and extended attack as potentially the riskiest of wildland fire operating environments. Quite often, fire conditions are at their worst while organization is at its minimum. Transitions from one level of incident organization to another, or command change, can be times of disorder, rapidly shifting tactics and poor communication.14 A number of the case studies in the Lessons Learned: Fatality Fire Case Studies package examine tragedies in command was in transition, providing opportunities to examine the role of transition as condition, contributing influence and causal factor.


Fire personnel interviewed in the study also cited fatigue as a serious problem. U.S. firefighting personnel are working too many consecutive hours on too many consecutive days and often on too many successive fire assignments. Additionally, firefighters are not receiving adequate rest while assigned to fire duty and many firefighters pay too little attention to adequate nutrition and hydration.15

It is the author's opinion that fatigue is a much greater firefighter safety issue than acknowledged by U.S. firefighting agencies. Fatigue mitigation receives a great deal of "lip service," but little effective action. This situation exists because addressing firefighter fatigue in the U.S. means that firefighting agencies must take on some very tough issues. Firefighter fatigue mitigation will require basic changes in operational period length and timing, assignment duration, the quality of rest afforded in fire camps and, most fundamentally, the way in which American firefighters are paid. Fatigue mitigation strategies carry a significant price tag; and fatigue has become the great, un-talked-about firefighter safety issue.

I focused on these particular principles for a number of reasons. First, TriData treats each of them as top priorities in the final report of the Firefighter Safety Awareness Study. In addition, each of these topics are interesting to operational level fire personnel and areas where real change can be effected by them. Finally, each of these topics is well supported by one or more of the nine case studies presented in the Lessons Learned: Fatality Fire Case Studies material.

However, one should note that the existing case studies can reinforce other key findings of the Firefighter Safety Awareness Study, including:

I found it important to discuss, at the beginning of each session, a key finding of the study. The Firefighter Safety Awareness study clearly advocates improvements in the realism and field relevancy of training provided to firefighters. These improvements will require a variety of training approaches, including simulations, case studies, interactive exercises and the dissemination of "lessons learned" through training. In addition to changes in training methodology, a fundamental broadening of content and focus is called for.

The Lessons Learned: Fatality Fire Case Studies course is certified by the National Wildfire Coordinating Group, and therefore is an objectives based package. Objectives describe precisely what is to be learned in terms of expected student performance, detailing how the trainee will learn to perform.

The purpose of the Lessons Learned course is stated in two objectives. First the training participant is asked to demonstrate awareness of the value in the study of historical fatality fires. Second, given a fatality fire case study, students are expected to identify causal factors using a risk management process and then determine the lessons to be learned from an analysis of those causal factors.16

The course intends that the first objective will largely be met through use of an introductory video tape. However, I have found that there is as much to be gained from a follow-on discussion that asks the participants to consider why they might study lessons from fires of the past. Typically, discussion ensues regarding four main points which are very timely and relevant to the U.S. wildland fire community.

Direct experience in short supply:

This discussion reinforces, and is reinforced by, major findings of the Wildland Firefighter Safety Awareness Study. According to the final report, the people interviewed and surveyed during the study raised major concerns about decreasing fire experience in the agencies' workforces. The study found that they are most concerned about the impact that declining experience has on judgement and decision making under the stress of the fireline environment.

In addition, the pool of federal employees who are willing and available to fight fire is shrinking due to a number of factors including downsizing, early retirements, disenchantment and de-motivation and an unwillingness to release collateral duty firefighters from their primary responsibilities.

Theory and Guidelines Ignore Human Factors:

Traditionally, fire control training has been too focused on the physical and the technical; all about fire behavior, strategy an tactics. While those subjects represent essential elements of a comprehensive training curriculum, we must recognize that firefighting is a human undertaking. Fire is the physical force that kills firefighters, but the decisions of human beings put them in the position of being killed. Fire control training has largely neglected the human factor.

Repeated Mistakes:

History teaches us that, in many fire entrapment situations, firefighters and tactical decision makers repeat mistakes that had been made on earlier fatality fires; sometimes with remarkable similarity. Nearly all tactical safety guidelines employed by U.S. firefighters derive from analysis of past fireline tragedies.

However, there is a growing dissociation between the behavior of firefighters and the stated safety guidelines of their agencies. Nearly forty percent of one thousand firefighters surveyed in the Firefighter Safety Awareness Study reported that standard safety orders are frequently violated.17

Lessons Learned Not Limited by Time or Technology - Still a Human Undertaking:

The record also shows us that neither time or technology have limited the potential for disastrous fireline accidents. Firefighting is a human undertaking, performed in a high risk environment, with countless variables, complicated by the complex and imperfect decision-making of people. That makes firefighting a dangerous business that cannot be made risk free.