Casey, one of the people who commented on our article about the most significant stories of 2011, pointed out to us that in addition to the one person that was killed April 28 on the prescribed fire near Trenton in southwest Nebraska, two others also died weeks and months later. Theresa Schnoor, 46, passed away at the scene, but Robert Seybold, 40, died May 18, 2011, and 37-year-old Anthony Meguire died at a burn center in Lincoln, Nebraska September 18, 2011. The three of them along with five others were conducting the prescribed fire on privately owned land.

May they all rest in peace.

Casey also pointed out to us an article written by David Hendee of the Omaha World-Herald that summarizes an investigation of the incident conducted by the Nebraska Fire Marshal’s office. The article is quite disturbing to read. Not because of any gore or graphic details, but because it points out many factors that might have resulted in a more favorable outcome if they had been handled differently. The issues included planning, organization, briefing, fire departments that were asked but did not assist, equipment, personal protective equipment, alcohol, and weather and how it related to the prescription.

This multiple fatality incident could be an example of the “swiss cheese” model developed by James Reason. A single error or unsafe act may not result in an accident, but multiple unsafe acts may align, like holes in layers of swiss cheese, to produce an unfortunate outcome.

We were not able to find a copy of the original Fire Marshal’s investigation report over the weekend, but if anyone has access to it, please let us know.

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UPDATE: January 10, 2012:

We found out more about Nebraska’s policy which makes it difficult to learn lessons from accidents on fires.

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Thanks go out to Casey