Adding to the list of common denominators of tragedy fires

More common denominators of tragedy fires.

Happy Camp Complex, 2014

(Photo: Happy Camp Complex, 2014, by Kari Greer.)

About forty years ago Carl Wilson, one of the early wildland fire researchers, developed his list of four “Common Denominators of Fire Behavior on Tragedy Fires”, that is, fatal and near-fatal fires.Carl Wilson

  1. Relatively small fires or deceptively quiet areas of large fires.
  2. In relatively light fuels, such as grass, herbs, and light brush.
  3. When there is an unexpected shift in wind direction or wind speed.
  4. When fire responds to topographic conditions and runs uphill. Alignment of topography and wind during the burning period should always be considered a trigger point to re-evaluate strategy and tactics.

Our study of the 440 fatalities from 1990 through 2014 shows that entrapments are the fourth leading cause of deaths on wildland fires. The top four categories which account for 88 percent are, in descending order, medical issues, aircraft accidents, vehicle accidents, and entrapments. The numbers for those four are remarkably similar, ranging from 23 to 21 percent of the total. Entrapments were at 21 percent.

But as Matt Holmstrom, Superintendent of the Lewis and Clark Interagency Hotshot Crew recently wrote for an article in Wildfire Magazine, Mr. Wilson’s common denominators only address fire behavior.

Mr. Holmstrom explored eight human factors that he believes merit consideration. I’m generously paraphrasing, but here are the areas he mentioned:

  1. Number of years of experience.
  2. Time of day (especially between 2:48 p.m. and 4:42 p.m.)
  3. Poorly defined leadership or organization.
  4. Transition from Initial Attack to Extended Attack.
  5. Earlier close calls or near misses on the same fire.
  6. Personality conflicts.
  7. Using an escape route that is inadequate.
  8. Communication failures.

He goes into much detail for each item and cites numerous fires which he said were examples. It is a thought-provoking article. Check it out.

UPDATE January 29, 2016. Larry Sutton authored an article in a 2011 issue of Fire Management Today (pages 13-17) that also explored the Common Denominators of Human Behavior on Tragedy Fires. At the time Mr. Sutton was the fire operations risk management officer for the U.S. Forest Service at the National Interagency Fire Center in Boise, Idaho.

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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.

9 thoughts on “Adding to the list of common denominators of tragedy fires”

  1. As a long time reader of this site, but first time commenting, I would like to introduce myself first to perhaps show relevance to my future comments. I am a federal fighter with IHC and engine experience and am currently an Engine Captain. Prior to my federal time I got my start on the local VFD. I have worked for both the BLM and USFS. I found these “Common Denominators on Tragedy Fires – Updated for a New (Human) Fire Environment” very interesting. I too have never found the current “Common Denominators” as nothing more than a talking point when teaching s130/190. However, I do understand and respect their relevance but perhaps they truly do need updated. I also feel that we sometimes overcomplicate firefighting with yet another checklist and every year we say the typical things listed in Idaho Firefighters comments in regards to bullet point 7-Safety. I personally don’t think we will take risk or safety serious until we admit the fact that people do die in this job. No fire or situation is completely safe and never will be. Do I think any fire is worth a life? Of course not. My ultimate job as a Captain and IC is to ensure that everyone on my truck/incident gets home safe. It is my nightmare that someday there could be a fatality or serious accident on my truck or incident. Is it worth taking the risk of a head on collision when driving to the supermarket? No but we do it every day. Is it worth the risk of blowing out a knee while jogging in the pre-season? No but we do this too. As a wild land fire fighter I have accepted the fact that our profession is not and never will be completely safe. It is my job and duty to strive for a 100% safe incident but to realize that it is imposable to achieve this.
    Point 4-I would also like to express my opinion on some of Mr. Homstroms points. First, I would argue that one of the biggest parts of successful IA is to be proactive. I currently operate in one of the high frequency IA “groups” described by Idaho Firefighter. I feel that we as a fire fighting culture teach to be reactive, and not proactive. I see this when we receive severity resources that are not used to operating in a higher tempo environment. I see this on a broader scale when we use risk and safety as an excuse not to engage. I am absolutely not advocating risky behavior or tactics, but in my opinion on larger extended attack fires the mindset seems to be how and why we WONT engage the fire. Why not let our higher trained and skilled fire fighters (IHC/SMJ) tell us what can and cannot be done? Will we not be eliminating more risk when we keep the incident smaller and less complex thus eliminating the mobilization of more resources?
    Point 5-I agree with this point but I feel it can be expanded upon. I feel that past success can give us a false sense of success and security. I’m sure we have all been on those early season fires where the grass doesn’t carry fire. At that time of the year the grass can be utilized as an anchor point. What happens to that anchor point in August? I realize that this is a rough example but I hope the point is taken. This can be expanded upon as to say the tactics and success that were utilized in the 2009 fire season were not necessarily effective for the 2012 fire season. I try to emphasis this with my crew every chance I get. We were successful today because….we would not have been successful today if this would have occurred. Again, I feel past success can be a major human factor. Individuals may have been dodging bullets and have not even realized it.
    Point 6-Idaho Fire Fighter nailed this one in my opinion. The best way this is mitigated is through communication. Everyone who shows up on a fire is there to help and actually can help through proper leadership and communication. That guy in blue jeans may have some excellent local knowledge of the lay of the laid and access issues. That resource from the opposite end of the country has a tool kit and slide show different from yours-which is a good thing and should be utilized. When being lead by sub-par individuals, there is always opportunity to “lead-up” and give tactful constructive criticism. I agree, we need to continue to have open debates on the fire line but we must have thick skin and keep an open mind.
    Point 8-As technology evolves communication complications will evolve with it. There will always be those unable to communicate with the newest and greatest device, and there will be those who we “can’t believe they are still using that.” The above statement doesn’t even get into the human factors part of the discussion. As stated by others and now myself, communication is at the root of every problem. I try to mitigate this by extensive pre-season work with cooperators. (Federal, State, Private) It has worked very well for me. It seems that others have more buy-in to what I say when I have trained with them, and they have seen me and spoke to me while not in nomex. I recommend all of you have these pre-season meetings.

    I would like to close and mention that I don’t feel that we fully understand the fire itself. There are areas that we can all improve upon and I feel that is fire weather forecasting. This will help us base all action on current and expected fire behavior. There are local wind events in every area that should be emphasized when non-district resources are present. There are local fuel moistures that should create trigger points and be monitored closely. Lately, I have been reading about Dry Slots and I encourage each of you to do the same. Thanks for the time and I would love to hear feedback.

    1. Thanks for your thoughts, RandomRamblings. You should contribute more often. I will check out Dry Slots.

      I find myself from time to time being involved in steering management’s focus. I seemed to hit a chord with you on #6. This is obviously a personal passion of mine. I would like to do my part to bringing more focus here. Would you (or anyone else) agree that this is a critical area that we can affect change in?

      Examples are helpful.


  2. After some conversation with Mr. Holmstrom, he has agreed to put on a class that he has prepared on this subject at our VFD. We are terribly excited!

    Local, State, and Federal firefighters have signed up to take the class.

    I truly believe in the material, and am honored to be hosting the class.

  3. It’s great food for thought. Anything to get us talking more about human factors is a good thing. I personally have no use for the 4 Common Denominators currently in use. They are too basic and general. Can anyone share how they altered behavior based on reviewing these? Perhaps they have passed their prime and it is time to retire them?

    My thoughts (and hopefully some insights) on the 8 new factors discussed by Matt Halstrom:

    1. Years of experience/quals present “at burnover.” There is a weak correlation from the data and no evident causal factor. Feel like this one is the weakest and even if you connect a cause it would be tough to affect much change due to the highly individualized nature of it. It is too easy to have the, “yeah but I know better” attitude. At best perhaps it is food for thought at high levels about on-the-ground oversight.
    2. Time of burnover. Powerful stuff. Easy to understand. Highly likely to affect change on-the-ground. It’s interesting how easily we will completely shut down ops for windy or wet conditions, but simply shutting down for a few high risk hours seems less common until after the fire has blown up of course.
    3. Poorly defined leadership. Very true. Some more rules might eliminate a few occurrences. We already know better. Deeper cultural change is necessary. How?
    4. IA to Extended Attack. This I feel like is the most powerful concept to get across. Matt does it well. #3 is most often present in these situations. I think some sort of structural change to facilitate transitioning quicker from the reactive to proactive mindset is necessary. (Quick responding and well practiced type 3 teams are huge. These fires are the most dangerous fire behavior wise when considering percent of perimeter growth (not to mention the higher chance of being less aware.)Matt nails it when he points out the large increase in our willingness to take risks when we have “lost the little one.” I don’t know how many times I have seen some of the poorest decisions when sawyers hang up a tree. Same concept with a lost IA. One more important consideration with these fires is that for all firefighters I would guess that we have the least amount of slides for these situations. We “catch” 97% of IA. We all spend a significant amount of time on large fires. Even if you are exposed to a higher percentage of expanding IAs, time spent in these situations is small compared with others. From my experience the best “groups” at managing expanding fires are high frequency BLM units and smokejumpers. The fact that these groups see the most of these incidents and arguably are better on average at managing them is telling.
    5.Earlier close calls. I am skeptical of this one. Is there some data to support? Causal factor would be hard to establish. I have anecdotal experience with close calls and no fatal accident. Seems like hindsight bias in pure form. It’s good to encourage people to speak up if it doesn’t feel right. I think it is powerful to share personal stories from people who didn’t speak up and then had something bad happen. I don’t think this is a Common Denominator though and if it were how would it change our behavior?
    6. Conflict on the fireline. This is huge. We have a culture that encourages rampant trash talking and passive aggressive behavior. We lack skill organizationally at conducting constructively critical conversations. We need our leaders to set the example and we need to train for this. I recently took an L-381 course and it was amazing how poor on average we are at this. These are single resource and above folks who already need this skill. If you were going to look at a causal factor of why middle-career folks are more likely to be involved in an accident I would start here. We promote experienced firefighters to be leaders of people and expect them to become good leaders mostly through OJT. Our L courses are a good step, but in my opinion they simply produce an awareness level without developing intrapersonal skills. This is the biggest weakness in our entire organization. Our agency tries to address this at broad levels by having Safety Journies and encouraging AARs. This is good but if your on-the-ground leaders don’t have the personal skill to engage in contentious real-time conversations then those bigger concepts don’t do much good.
    7. Return to Safety.
    If we didn’t have a problem with this then we wouldn’t have any burnovers. I would say most of us our shooting from the hip when we consider these. We rely mostly on our gut and find favorable inputs to our calculation of these. We could develop very accurate mathematical calculations and eliminate a whole lot of human error in establishing realistic escape routes and safety zones. Our organizations and us the firefighters don’t really want to do this though, because the truth is we would be forced to disengage from a huge number of fires that we currently engage in, especially when it comes to IA. We will continue to lie to ourselves until we truly believe that our lives are more important than any amount of burnt resources. Despite the politically correct propaganda firefighters and the organizations we work for don’t believe this in the altruistic sense that is presented. Of course we wouldn’t trade anyone’s life for “one tree” or “one house.” This is a false choice though. If we don’t risk firefighters lives at all then we are risking millions of acres of forests, thousands of homes, hundreds of animals, and vulnerable public. Way off track, but to me this gets to the heart of poor risk management. We misconstrue reality in order to fit the politically correct answers of “we have LCES in place,” “no tree is worth a life,” and “we don’t change the way we fight fire to protect structures.” If anyone believes these statements are accurate reflections of what is actually happening on the ground you need to get out more. I can go on, but I would rather see what you all think on this one. Bringing it back around, yes I agree we fail to accurately plan and assess escape routes routinely.
    8. Communication Failures.
    I agree with Matt that this is always present in accidents. Playing devil’s advocate I would say that it is impossible not to have communication failures. We will always look to this element for the “if only” moment. In reality perhaps people are already on a poor risk management path and one more piece of information may not change the outcome. In fact generally speaking it could just as easily push a near miss situation into a fatality. I’m not trying to say this isn’t important to look at. Perhaps putting a general statement out there like this will help people that tend to under-communicate to share info a bit more and also scrutinize our assumptions more? I feel like this is a message that we have been beat over the head with and perhaps we have reached our current capacity? Although I believe we are doing a poor job institutionally to keep up with technology which could expand our ability to gather and process substantially more information.

    Great job Matt. I will do my part to continue this conversation as you had hoped. Hopefully my thoughts contribute to this as well.

  4. I got to spend a week training with Mr. Holmstrom and some of the Lewis and Clark crew.

    What a pleasure that was. He is one of the most squared away people I have ever been around.

    We talked at length about human factors, and I am convinced that he is on the right path.

    He invited me to Ted Putnam’s mindfulness talk that year, but regretfully I could not attend.

    I have really bought into what Mr. Holmstrom is talking about.

    Great find Mr. Gabbert.

  5. When, and why, was Wilson`s 5th Common Denominator dropped ?

    #5 “Some suppression tools, such as air tankers and helicopters, can adversely affect fire behavior.”

    In military or LE terminology, this is called “friendly fire.”

    1. If you say stuff like that you need to either admit you’re being facetious, or supply documentation to back up your claim. As far as I know it is not true.

      1. Cedar Fire LOOD was partially attributed to uncoordinated firing operations. There are others back in time, plus several near misses, (few actually reported).

        I am not being a wise guy, just want to know why #5 was deleted.


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