Unlearned lessons in Nebraska

When we report on serious accidents or fatalities on wildfires, we always try to obtain a copy of the official investigation report from the jurisdiction involved. But for the incidents on federal land at least, and on other lands in most of the western states, the responsible organizations almost always make the report available freely and conveniently, usually on the internet.

The primary reason to distribute accident reports as widely as possible is to reduce the chance of similar accidents. We call these “lessons learned”. There are entire organizations and web sites devoted to this concept, such as the Wildland Fire Lessons Learned Center, the U.S. Army’s Center for Army Lessons Learned, and the Department of Homeland Security’s Lessons Learned Information Sharing site. We put together the document titled Infamous Wildland Fires Around the World, which is a partial list, by date of the year, of some of the more famous, or infamous, multiple fatality wildland fires around the world over the last 150 years. We hope that firefighters will remember these accidents and the lessons learned from them.

But it is much more likely that mistakes made on fires in Nebraska will be repeated.

When we searched for an official report about the triple fatality on the April 28, 2011 prescribed fire near Trenton, Nebraska, we came up with nothing. We linked to a pretty good newspaper report, and asked if our readers were aware of an official report on the incident. One them told us that there was a multi-step process that involved many exchanges via snail mail to get a copy of a fire accident report in Nebraska. And it usually takes about a month, they said.

We called Jim Heine, the Assistant Fire Marshal in Nebraska and asked him how to obtain a copy of a report. He said it was a “simple one-step process”. But it turns out that there are five six steps.

  1. Complete an application form to request the report. The form can be downloaded from the Fire Marshal’s web site, printed, and completed by hand.
  2. Send it to the Fire Marshal’s office by fax or by snail mail.
  3. The agency’s legal counsel reviews the request. If it is approved….
  4. The Fire Marshal’s office sends you an invoice.
  5. You send the Fire Marshal’s office the payment for the report (a typical fee is $3.50).
  6. The Fire Marshal’s office snail mails you the report.

We asked Mr. Heine why the reports were not available on the internet. He said “If you had a family member who died on a fire would you want the report to be public?”

We have heard of many family members who had loved ones that died on a fire who are vehement that the circumstances and lessons learned become public. They would like to prevent other families from losing a loved one and going through the same pain and suffering. Two recent examples that come to mind are the CR 337 fire in Texas last year and the Carson Helicopter crash in 2008 on the Iron Complex fire near Weaverville, California.

Lynette Hamm’s son, Caleb Hamm, passed away on the CR 337 fire in Texas last July. When told about Nebraska’s policy on accident reports, she said:

I can only surmise Mr. Heine has never lost a loved one before. If so, I believe he would want to get to the bottom of it, however it happened, and have those findings available for future training. If the firefighting community really wants to learn from past mistakes/accidents, wouldn’t we want those reports to be made available to everyone in the hopes of preventing another occurrence? I would think so.

Nina Charlson’s son, Scott Charlson, died along with eight other firefighters and air crew members in a helicopter crash on the Iron Complex (or Iron 44) fire in 2008. Ms. Charlson has been very active in following up on the investigations of the accident. When she and family members of other firefighters attended a National Transportation Safety Board forum in November, she released a statement that included the following:

…We cannot bring our loved ones back but if we can stand up for safety changes for future passengers – that is what we want to do.

When told about Nebraska’s policy, she replied in part:

I think it is reasonable that if the victims families did not want to have details made public (maybe their firefighter made a stupid mistake) they could request it – but still firefighters should have the information for future safety measures.

The purpose for any future actions of the Iron 44 families part is definitely for the purpose of safety.


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Author: Bill Gabbert

After working full time in wildland fire for 33 years, he continues to learn, and strives to be a Student of Fire.

10 thoughts on “Unlearned lessons in Nebraska”

  1. If I can plead my case, in the body of another post (https://wildfiretoday.com/2012/01/08/followup-three-fatalities-on-2011-prescribed-fire-in-nebraska/) a similar statement was made – “The issues included . . . fire departments that were asked but did not assist . . .” By calling it an issue among many other issues, an uninformed reader could understandably assume that fire departments have a duty to assist with Rx fires. Personally, I think participation in Rx fire is great OJT, but it is not something they should be obligated to do. That they should be required is a point of view I’ve heard a number of times in the arena of fire on private ground.

  2. Well, I’m just one of the hayseeds who grew up out in 1955 Nebraska, but it seems like a lot of conclusions are coming a little too easy here. So some info/opinion:

    As has been said, the three who died were private citizens working on private ground.

    Before the Nebraska Fire Marshals Office is crucified any further in this court of public opinion, how about the process first be allowed to run its course. I have not read the report, but as the Fire Marshals Office is an enforcement agency, I don’t believe its intent was lessons learned or FLA. And from what I understand, the OWH story essentially IS the report, so the information is far from secret.

    Also, before the fire departments in that area are assigned any more implied responsibility for this incident, a lot more homework needs to be done. The overwhelming majority (over 90%) of Nebraska fire departments are 100% volunteer. A look at the calendar would show that April 28, 2011 was a Thursday and no doubt the members of the fire departments were all working their regular jobs (you know, pay the bills, feed the family). Even if the policy of the fire district was to assist with Rx fires when possible, who would have been available? Should I assume that the opinion here is that in addition to all the responsibilities thrown at volunteer fire departments (structure fires, wildland fires, rescue, fire prevention, EMS, hazardous materials, sports stand-by – should I continue?) they must now ALSO stand by at every Rx fire in their district?

    1. Casey, you said:

      Should I assume that the opinion here is that in addition to all the responsibilities thrown at volunteer fire departments…they must now ALSO stand by at every Rx fire in their district?

      No, you should not assume that. I mentioned fire departments in my reply to Bruce because he was asking if firefighters were killed in the incident.

  3. I am preparing a presentation about firefighter safety and had occasion to look at the USFA 2011 Firefighter Fatality site. None of these folks are listed at that site. Would that have been because they were working as or for a private contractor?

    1. Bruce, it is my understanding that they were not firefighters, but were landowners or they were assisting the landowner. Three fire departments were asked to assist or at least stand by during the burn project, but they declined.

  4. Perhaps we should keep in mind that these folks were not government employed firefighters. They were farmers/ranchers doing agricultural work.

    1. Karl, for me the issue is, should the lessons learned from this and other accidents be kept secret? If the next farmer, rancher, volunteer firefighter, or full-time firefighter that is involved in suppressing a fire or putting fire on the ground could learn a lesson from a previous accident, it might save their lives. IT MIGHT SAVE THEIR LIVES, while preventing the pain and suffering of their surviving families. And at least SOMETHING positive might come from a terrible incident.

  5. ‘We asked Mr. Heine why the reports were not available on the internet. He said “If you had a family member who died on a fire would you want the report to be public?”’

    I would remind Mr Heine that he can walk into any
    Federal Depository Library ( there are 12 in Nebraska including four in lincoln where I assume Mr. Heine works) and pull a copy of the South Canyon Fire Report and ftal fire reports off the shelf.

    We are all better served when government is transperant.

  6. Outside of Lincoln and Omaha it is still 1955 in much of Nebraska and Red Skies of Montana is playing at the local Theater. If you think places like Cooke City Montana are isolated, try the Sandhills.

  7. The truth at times can be very ugly. But in order to help prevent future accidents, injuries and deaths we all need to learn from our past mistakes. Good solid investigation that reveal real mistakes or short-commings need to be distributed to all the involoved and intrested parties. The information may be disturbing, graphic and reveal a less then a perfect image of persons involoved, but it helps us save others.

    It can be very painful for friends and family members since most want to remember the deceased in a good way.

    If we do not learn from past mistakes we are doomed to repeat them.


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