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.