Using Fatality Fire Case Studies and a Lessons Learned Approach to Achieve Desired Changes in Firefighter Safety


Stimulated by the tragedy of the 1994 South Canyon Fire, on which fourteen firefighters were killed, five federal agencies in the United States contracted a major study to examine wildland fire safety problems in depth. The study set forth a plan to move the organizations from their current safety environment to a new and desired safety culture.

Among the study's key findings, are strategies to drive fireline safety practices using a risk management process, improve communications and mitigate hazards caused by excessive fatigue and the transition of command. Effecting these improvements, will require fundamental changes in the ways in which firefighters are trained in the U.S..

Training must be made more realistic, and explicitly prepare firefighters to maintain situational awareness, respond to identified hazards and unexpected events, and make effective decisions under stress, The study advances strategies to prepare firefighters using case studies, by critiquing authentic actions and using a "lessons learned" approach.

This paper details an approach to achieving those aims while simultaneously raising awareness of the study and its findings at the lowest, field levels of the client organizations.

The Wildland Firefighter Safety Awareness Study

Lessons Learned: Fatality Fire Case Studies

Combined Impact


Michael DeGrosky

Michael DeGrosky is principal consultant at Michael T. DeGrosky & Associates and currently serves as the President of the International Association of Wildland Fire.

This paper was originally delivered at the IAWF's Wildland Fire Safety Summit in Sydney on 5 November 1999.