21 issues frequently identified in firefighter entrapment reports

Can lessons actually be learned?

Horse Park Fire
The Horse Park Fire in Colorado, May 31, 2018. Screenshot from the Hotchkiss Fire District video.

The 43-page facilitated learning analysis about the entrapment on the Mendocino Complex of Fires was well-researched and skillfully written. Six firefighters received burns and other injuries when they had to escape from the fire by running through unburned vegetation.

The intent of the analysis and hundreds of others like it is for firefighters to gain knowledge from the dozens of identified lessons learned that were meticulously documented, hoping that they will not be repeated by those who read the report.

That sounds very straight forward and simple.

But will reading about something that occurred on a fire months or years ago and hundreds or thousands of miles away actually influence someone’s behavior, performance, or decision making ability? Intuitively, we may say, “Yes. Of course. Learning about something that went wrong on an incident will keep us from making similar bad decisions later.”

A comment left by Paul regarding the article about the facilitated learning analysis was interesting:

Nothing “new” in the “Lessons Learned”. After decades in the fire service, makes me wonder if Lessons can be really be learned (and applied) at an organizational level. Seems they are constantly learned at the personal level.

Paul makes a good point. Those of us who have read numerous after action reports have seen almost all of the identified lessons many times before. Below are 21 issues mentioned in the Mendocino Complex report that were identified on the August 19, 2018 incident-within-an-incident.

  1. Interpersonal communications
  2. Communications system (radios & repeaters)
  3. Organizational structure
  4. Inadequate briefings
  5. Span of control way out of whack
  6. Inadequate knowledge about the real-time location of the fire
  7. Crew resource management
  8. See something say something
  9. Play the what-if game
  10. Turn down assignment
  11. Interagency rivalry
  12. Inadequate lookout ability due to terrain
  13. Metro firefighters and those from a different fuel type thrown into a complex wildfire situation
  14. Escape routes
  15. Safety zones
  16. Not knowing the real-time location of firefighting resources
  17. Holy Grail of Wildland Firefighting
  18. Burn victims not being sent to a burn center
  19. Very long travel times to fireline assignments
  20. Personnel shortages on Incident Management Teams and Unable To Fill resource orders on fires affecting tactics and safety
  21. Failure to declare an Incident-Within-An-Incident

Will identifying these issues still another time in a well-written document help prevent them from recurring? We have always assumed it will. But if so, why do the well-intentioned reports continue to list many of the same items?

In a perfect world an important lesson to be learned would be described once in a report. It would then become global knowledge in the firefighting world and the issue would never again have to show up in an after action review.

If these documents and formal classroom training is what Paul refers to as the “organizational level”, does he have a point that the most frequent way firefighters learn is from personal experience?

How do we increase the effectiveness of lessons learned reports?

Is there a different, or innovative method that could transplant these lessons into the personal mental “slide shows” that experienced firefighters consult and refer to when they are faced with a tough decision in the field?

Without doubt, someone will say all we have to do is abide by the 10 Standard Firefighting Orders and 18 Watch Out Situations. The Orders have been around for 62 years. Someone else just saying “follow them” will not magically make it happen. That has been said millions of times in the last six decades and still, between 1990 and 2015, an average of 17 wildland firefighters were killed each year. Continuing to do the same thing while expecting different results is not realistic.

Typos, let us know HERE, and specify which article. Please read the commenting rules before you post a comment.

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.

15 thoughts on “21 issues frequently identified in firefighter entrapment reports”

  1. Having worked on wildland fires in Montana for a month in 2000, I found coming from West Australia’s flat landscape to the steep terrain of north west U.S. an essential asset of a moving map displaying both topography and current fire location would have been invaluable, especially as the fire teams under my control were not locals either.
    As more major fire incidents will be managed by crews drawn from many remote geographic locations it will become vital for visiting suppression resources to have the most current active data on terrain, known vegetation types and essentially any known natural refuges and water supplies, to ensure fire management decisions at the fire face are based on the best possible knowledge available, thereby hopefully avoiding dangerous situations that can and will lead to entrapment.

  2. Bill. The Holy Grail as you describe it already exists. Blue Force Technology and Verizon offered to work with the USFS in 2012 to develop such a system. San Dimas was not interested in pursuing this product, they were looking at another product. Lots of tech out there, just need a champion to see it through. One has to wonder though if the Command net was spotty ( as it often is) why would we believe the Holy Grail would flawless? There will always be network issue with type of technology.

  3. Experience plays a major role. So do the Fire Orders and Watchouts. Strategy and tactics have become suspect over the last several years, creating more risk. We need to get back to the basics, and continually apply them on the 4-6 week duration fires that are more common these days, and stay vigilant every day, through every transition. DIVS play a key role in this, which brings me back to experience. Be alert, keep calm, think clearly, act decisively.

      1. ^^^…(eyes rolling out of my head)
        90% of Safety Officers are 99% ineffective. There are a few who are useful, but usually just as extra operations folks. Anyone who stands next to a 215 and proclaims checks the safety box is a detriment to creating larger margin between risk and humans. Once we learn to quit perverting the conversation into subjective risks and controls, we can begin having real conversations about the most important risks out there. Human factors. We make the decision to undertake the risks? Why? Once we start answering those questions instead of pointing at the “control” measures or “mitigations” that “could have” prevented an accident, we will perhaps begin to make progress. Gadgets, checklists, charts, organizational structure, communications, etc… can all help better inform individuals and systems, but ultimately it all fails when human factors intervene. The one repeat lesson in all of these events, is that human factors will intervene. As you are pointing out, we already have a pretty good list of the what and the how. We need to keep focusing on the why, which fortunately our lessons learned often point at. Perhaps we need to start naming and calling out the heuristics more deliberately?

  4. Many missed issues- Don’t fall in love with a plan being one of the biggest. Reading the synopsis of the day, it seemed obvious to me that Plan ‘A’ was out of time and Plan ‘B’ should have been enacted. But having spent plenty of time on these ‘project’ fires in R4, after week 2, they become just a meat grinder where folks come to get tickets punched and plenty of out of their element folks are left in charge of things they have no business being in charge of. Having lived through this stuff for many years, (over 3 decades) the changes have seen haven’t made fireline work safer.

  5. The Holy Grail of Wildland Firefighter Safety is a system that could track in real time the location of firefighters AND the fire, all displayed on one screen. This data should be available in real time to key supervisors and decision makers in the Operations and Planning Sections on fires. Knowing the positions of personnel relative to the fire would be a massive step in improved situational awareness and could reduce the number of firefighters killed on fires. Too often firefighters have been surprised, overrun, and sometimes killed by a rapidly spreading wildfire when they did not know where the fire was and their supervisors did not know the correct, actual location of the personnel.

    I first wrote about the Holy Grail of Wildland Firefighter Safety in 2013.

    Not everyone a fire would need to monitor it all the time, but at least one person should be given the responsibility to be sure that a rapidly spreading wildfire does not overrun the location of firefighting resources. Darkness, smoke, and terrain can obscure the location of the fire from firefighters on the ground.

    The report on the Mendocino Complex mentions several times that firefighters did not know for sure where the fire was. In addition, for a while no one knew where the six firefighters were that were running from the fire. It was quite some time before they were located after searching with trucks and a helicopter.

    A drone orbiting high over the fire far above air tankers and helicopters could use near infrared optical equipment to see through smoke. A safety officer, for example, could be given the duty of ensuring that firefighters are not surprised and become entrapped by flames. Depending on the size of a fire and its activity it might only take one person to be sure firefighters are in safe positions. More complex or more active fires might need more.

    The locations of firefighters could be provided by the newer Bendix-King radios that have built-in GPS receivers. Small devices that could fit in a shirt pocket could do the same thing and be provided by the interagency fire warehouse system, shipped to the fire like radio caches. The data could be sent through an on-the-ground mesh network, device to device, and be relayed to a server by cell phone towers or through a receiver on the drone orbiting the fire and then to a cell tower or satellite.

    Ideally a safety officer given this duty would be at the fire and familiar with the fuel, topography, and weather. But in a pinch, or perhaps during the very early stages of a fire it could be done by a qualified person anywhere, as long as they had an internet connection.

    In addition, it is very important for the Planning and Operations Section Chiefs to know in real time where the fire is so they can better plan and deploy resources where they will be the most effective. Often Incident Action Plans are made using out of date fire location information and by the time firefighters get to their assignment in the field it becomes obvious that the plan needs to be changed and firefighters have to be relocated due to movement of the fire.

    Fire Behavior Analysts that could continuously observe the fire with the available video could make much more valuable and accurate Fire Behavior Forecasts.

    1. So…..firefighters are engaged in fire suppression without a lookout? You know, a designated person who can SEE the fire? Hmmm. Technology won’t be able to fix the absence of fundamentals.

        1. What I mean is: time after time we read reports after near-miss, injury, or fatality fires and a common theme is firefighters not knowing where the fire is in relation to them. My concern is the act of embracing technology in order to provide firefighters with what they should have had all along is a perfect example of treating the symptom not the problem. Another concern is a cultural adaptation over time which results in over-reliance on tech giving a false sense of security leading to more injuries and deaths to firefighters. I happen to firmly believe the idea, cultivation and use of the survival fire shelter is the pre-eminant example of this deadly phenomenon. The Canadians have it right in this regard. God bless em

  6. Bill, I must have missed it, but who on an incident (OSC, IC, DIVS, SO?) would be responsible to monitor the Holy Grail if everyone is transmitting their locations? How would the fire’s edge or spot fires be tied into this?

  7. Usually it a 20 man crew, my sons crew pares up two men , and they stay in sight of each other, and in sight of the next two, everyone knows wear everyone is,usally there fire boss, and the crew bosses go check out the area, no matter what has been said, people reading terrain map, don’t read them right some times, they pick out safety zone, hassards ect. Human error can kill, my son been wildland firefighting for 6 years and his team has a great track record, be safe, and getting the job done, is what it all about.


Comments are closed.