Lessons Learned: Fatality Fire Case Studies

Fortunately, in 1997 the National Wildfire Coordinating Group (NWCG) initiated a project to develop a training course that required trainees to critique the actions of firefighters and tactical decision makers using a lessons learned approach. The intent of the course is to examine various case studies of fatality fires in order to derive specific lessons learned on an individual basis.

The purpose of the Lessons Learned training course is to use historical fatality fires as a learning tool to help tactical decision makers, from advanced firefighter through Operations Section Chief, avoid making similar mistakes in the future. The course is designed as a series of nine case studies. The time required for the course ranges from four to 16 hours, depending on the number of case studies presented. The designers intended the course as a stand alone component of annual safety refresher training, as part of an academy curriculum, or to enhance other training courses.7

The fatality fire case study approach is not entirely new. Studies of fatality fires have been used as a teaching tool in the U.S. since the early 1970s, when the Los Angeles County Fire Department and California Department of Forestry developed formal courses around casualty fires. The NWCG included the analysis of fatal wildfires fires in the 1978 version of their Crew Boss course.

The contemporary Lessons Learned course materials combine the benefits of the fatality case studies approach with a methodology employed in military "staff rides," a training technique conveying the lessons of historical battles for current application. The approach requires participants to learn the facts, understand cause and effect and analyze the results. When conducted effectively, this analysis challenges the participant to decide what these cause and effect relationships mean to them, or what lessons can be learned for immediate or future application. 8

Staff rides include extensive, systematic, preliminary study and visitation to actual battle sites. The Fatality Fires course employs concise background material from investigative reports and replaces on-site reconnaissance with video presentation in the interest of making the training accessible to as many participants as possible while minimizing time requirements, logistics and cost.

The cornerstone of the Lessons Learned curriculum is its inclusion of a five step risk management process, adapted for wildland fire operations from a method employed by the U.S. Army. The risk management process provides firefighters and tactical decision makers with a decision making aid for identifying and mitigating hazards during fireline operations. The process provides a framework within which firefighters can better apply existing tactical safety guidelines used in the United States.

This approach directly addresses a key recommendation of the firefighter safety study. According to the study report, the agencies must "prepare firefighters with a framework for applying (versus just "knowing") fire safety guidelines, and influencing the decision making process." The report goes on to say that "Training firefighters to use a common risk management process will provide such a framework."9