Winter 2014 ▲ Vol. 3 Issue 4 ▲ Produced and distributed quarterly by the Wildland Fire Lessons Learned Center

What’s Up with Incident Reviews?

By Travis Dotson Reviews. Reports. Investigations. Chances are good that you have heard all three of hese days it seems there are incident reviews for everything—from a decision to not cut a these terms used interchangeably. But, are tree, to a minor vehicle accident, to the full-on fatality report. There are definitely more they interchangeable? At the Wildland Fire reviews and more types of reviews out there than ever before. Lessons Learned Center, we use the term T In the eyes of the Wildland Fire Lessons Learned Center, that’s a good thing—it’s more material to “reviews” to cover all of them. They are all housed in our Incident Review Database: use for learning! However, with all of these different types of reviews, it sometimes gets [http://www.wildfirelessons.net/irdb]. confusing—especially when they all look so different, even the same type of report. Regardless of the specific type or format of For instance, the Serious Accident Investigation (SAI) and Facilitated Learning Analysis (FLA) can look the document, we place them all here drastically different. In some cases, we have multiple reports on the same incident (Yarnell). What under the generic umbrella of “reviews.” gives? Let’s see if we can shed some light on this issue.

Let’s start with our most -used guidance. The 2014 Red Book (Interagency Standards for Fire and Aviation Operations) says there are 10 different types of “Reviews”. [See table at top of Page 3.]

Please Because so many reports officially fall under this category, let’s focus on the “Lessons Learned Review”. The Red Book says: [The yellow highlight—throughout this article—is mine.] Provide Us with Your The purpose of a LLR is to focus on the near miss events or conditions in order to prevent potential serious Input incidents in the future. In order to continue to learn from our near misses and our successes it is imperative to conduct a LLR in an open, non-punitive manner. LLRs are intended to provide educational

opportunities that foster open and honest dialog and assist the wildland fire community in sharing lessons learned information. LLRs provide an outside perspective with appropriate technical experts assisting involved personnel in identifying conditions that led to the unexpected outcome and sharing findings and recommendations. https://d

Fairly straightforward, right? If something bad almost happens (or one of those rare occasions in which we bit.ly/2mcfeed try to learn from something going right), be nice to those involved and help the rest of us learn from their back story. Pay attention to that last Red Book sentence (above). It’s a big deal in the incident review world.

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In this Issue

How do we really learn from an event? Page 2 Two entrapment reports/learning approaches. Which works for you? Page 5

RLS: Share your lessons rapidly with others Page 7 IHC Superintendent reveals his insights on reviews Page 8

Difficult suggestions on what you should be leaving behind Page 11 1

Ground By Travis Dotson

Fire Management Specialist Wildland Fire Lessons Learned Center Truths [email protected]

Where is the Learning?

first off, let’s get one the ones we focus on. The reports thing straight: I immediately gain new skills or OK, “Ground Truths” is behaviors from are the super the world according to Travis simple two-pager types with Dotson. That’s all. Just like some concrete, actionable lessons: incident reviews are the world  Use a drill to roll hose according to that author or team. I  Move away from flame have no power over anything other when your saw vapor locks than maybe what people talk about  Practice making a “back- in line for chow. Some people like country litter” reading my rants. But, then again, people like watching monkeys at That stuff makes sense the zoo. So if you want to complain immediately. It sticks with me and to my supervisor about what I say I put it into practice when faced because it’s different from what with a similar situation. These are you think, go for it. But keep in mind, I’m not writing policy the type of reports I think we learn the most from. or even influencing it. I’m just a knuckle-dragger with no education who stumbled onto a keyboard. How much we learn from an incident (especially a high- profile fatality) is a different deal. That process involves Now, my thoughts on reports/reviews/investigations— questions, discussions, simulations, and most importantly: whatever you want to call them. I have one big beef with time—which requires patience. (See my previous “Ground reports, and it’s not even with reports themselves. It’s how Truths” rant on Patience.) much emphasis we put on them. So please don’t confuse learning from an event with just Learning from an event is not the same as writing OR writing OR reading a report. That’s not how it works. reading a report. That’s my only issue. Learning from an event is a very involved process. The report is just one part If you’re writing reports, focus on telling the story in detail. of that process. And, in some instances, it’s not even Include pictures, videos, quotes and firsthand accounts as necessary. often as possible. Remember, your report is a small (but important) PIECE of the process. I have learned a lot from the events surrounding July 6, 1994. And not one of When you read the things I learned is a reports, don’t expect result of just reading the lessons to be the report. Everything spoon-fed to you on I’ve learned has come paper. That’s not from discussion with where the learning is. people I know and Learning comes from respect, walking the the intentional actual ground, hearing interaction you from those who were engage in after the there, and participating reading. in the Staff Ride. The report is just context. Learn on, Tool Swingers. Now there are reports I think we learn instantly from, but they’re not

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From the 2014 Red Book: [Continued from Page 1] Review Types and Requirements It highlights a difference in perspective that results Delegating or Type When Conducted in such different looking reports. The charge to Authorizing Official identify conditions (rather than “cause”) gets a lot Annually, or Local/State/Region/ Preparedness Review of folks riled-up. (More on that later . . . ) management discretion National After Action Review Management discretion N/A According to the Red Book, at a minimum, an LLR Geographic Area should do the following: Fire and Aviation Safety As fire activity dictates Coordinating Group Team Review • Identify facts of the event (sand tables may be helpful in the process) and develop a chronological Safety Assistance As fire activity dictates Local/State/Region/ narrative of the event. Team Visit National

Aviation Safety Assistance As aviation activity State/Regional • Identify underlying reasons for success or Team Review dictates Aviation Manager or MACG unintended outcomes.

Refer to NWCG Large Fire Cost Review Agency Director • Identify what individuals learned and what they Memorandum #003-2009 would do differently in the future.

Individual Fire Review Management Discretion Local/State/Region/ • Identify any recommendations that would National prevent future similar occurrences.

Lessons Learned Review Management Discretion Local/State/Region/ • Provide a final written report including the above National items to the pertinent agency administrator(s) Rapid Lesson Sharing Management Discretion N/A within two weeks of event occurrence unless otherwise negotiated. Names of involved personnel

Escaped Prescribed Fire See Interagency Prescribed Fire Planning and should not be included in this report (reference Review Implementation Procedures Guide (PMS 484) them by position).

Peeling Back More Layers Sounds great. But how often do we see LLRs? It seems like most of what we see is the FLA. Where do those fit in?

More clarification from the mighty Red Book: FLAs are a type of Lessons Learned Review.

That’s a bit confusing. So, let’s peel back one more layer.

Check this out, again, from the Red Book:

• A LLR should not be used in lieu of a Serious Accident Investigation (SAI) or Accident Investigation (AI) if the SAI/AI criteria have been met.

• FS [Forest Service]- Facilitated Learning Analysis (FLA) may be used for incidents meeting the AI criteria.

Again, a little confusing.

To me, what it says is “No LLR” if it’s an “Accident” (see definition below)—unless you’re the U.S. Forest Service (who can use an FLA, which is “a type of LLR”). Are you tracking? I think I need a map. [Check out my map above right.]

‘AI’ and ‘SAI’—What are They? So now we can talk about the Accident Investigation (AI) and Serious Accident Investigation (SAI). First off, what are they?

The good ole Red Book says:

• Wildland Fire Accident An unplanned event or series of events that resulted in injury, occupational illness, or damage to or loss of equipment or property to a lesser degree than defined in “Serious Wildland Fire Accident”.

• Serious Wildland Fire Accident An unplanned event or series of events that resulted in death, injury, occupational illness, or damage to or loss of equipment or property. For wildland fire operations,

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Flashback on Serious Accident Reports a serious accident involves any of the following:

1937 . One or more fatalities; Blackwater Fire – 15 Firefighter Deaths “Regrettable as it is, it must be recognized that in man’s . Three or more personnel who are inpatient hospitalized as a direct result of or control of forest fires some accidents will occur—just in support of wildland fire operations; as in city fire protection—without fault or failure on the part of anyone. Here was brought about a peculiar . Property or equipment damage of $250,000 or more; and/or combination of circumstances rare in forest-fire history. It is reassuring to know that such occurrences are . Consequences that the Designated Agency Safety and Health Official (DASHO) infrequent. Not since 1910 have so many lives been judges to warrant Serious Accident Investigation. lost on a single national forest fire, and fatalities from burning are very uncommon, although probably more than 100,000 men fight fires in the average year.” Basically, if people or equipment are damaged it’s an “Accident”. And if a lot of people

Fire Control Notes; Dec. 6, 1937 or equipment are damaged, it’s “Serious”. Either way, there should be an “investigation” (unless you’re the U.S. Forest Service). [See Red Book table below that clarifies when to 1949 Mann Gulch Fire – 13 Firefighter Deaths use what type of investigation.]

“The survivors and one of the men who later died in the hospital said they believed all of the men would have been saved if they had followed the foreman’s lead in Wildland Investigation getting into the area burned by the escape fire. The Board of Review recommends that firefighter training Fire Event Type include training in the use of escape-fire methods, even though occasions for the use of this method are Serious Serious Accident relatively rare.” Wildland Fire Accident Investigation Resume of Report by Board of Review; Dec. 5, 1949 (SAI) FS - Coordinated Response Protocol 1953 Rattlesnake Fire – 15 Firefighter Deaths “It is evident that here, as generally throughout the Service, there are technical aspects of fire behavior that are not fully understood. The general strategy, tactics Wildland Accident and generalship employed on the fire were in Fire Investigation (AI) conformance with acceptable fire suppression Accident FS - FLA may be used principles.” Investigation Report; July 9, 1953

1966 Entrapment/ SAI, AI, LLR, Burnover depending on severity Loop Fire – 12 Firefighter Deaths “We want facts—what happened, how and why. Then we want those facts studied carefully and evaluated to

formulate sound conclusions and recommendations— Fire Shelter SAI, AI, LLR, how could the final outcome, or any of the occurrences Deployment depending on severity or situations leading up to it, have been avoided? What mistakes or weaknesses or oversights are there that can be prevented in the future? You must follow every Near-miss LLR, AAR possible lead to determine how we can tighten up our safeguards to prevent a similar disaster in the future.” Letter from USFS Chief Cliff to Deputy Chief; Nov. 2, 1966

1994 South Canyon Fire – 14 Firefighter Deaths “The ‘can do’ attitude of supervisors and firefighters led Basically, if people or equipment are damaged to a compromising of Standard Firefighting Orders and a lack of recognition of the 18 Watch Out Situations.” it’s an “Accident”. And if a lot of people South Canyon Fire Investigation Report; Aug. 17, 1994 or equipment are damaged, it’s “Serious”. 2001 Thirtymile Fire – 4 Firefighter Deaths Either way, there should be an “investigation”—unless . . . “Failure to adequately anticipate the severity and timing of the burnover, and failure to utilize the best location and proper deployment techniques contributed to the The Red Book includes some important differences among agencies: fatalities and injuries. Leadership, management, and command and control were all ineffective due to a variety • BLM - BLM Accidents that involve fire and aviation employees or equipment will be of factors, such as the lack of communication and investigated according to the requirements stated in this chapter. Investigations will miscommunication, fatigue, lack of situational awareness, indecisiveness, and confusion about who was occur regardless of land jurisdiction. Facts will be collected, causes (organizational in control. factors, local workplace factors, unsafe acts) identified, and an accident investigation All 10 Standard Fire Orders were violated or disregarded report produced. The report will include recommended corrective actions and control at some time during the course of the incident. Ten of the measures. 18Watch Out Situations were present or disregarded at some time during the course of the incident.” • The Facilitated Learning Analysis (FLA) process may be used as a supplemental element Thirtymile Fire Accident Investigation Report; to required BLM accident investigation processes. [Continued on Page 6] Oct. 16, 2001

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Two Entrapment Reports: Two Different Approaches to Learning

Which one suits you? Tell us at: [email protected]

[Click on covers to view.]

Holloway Fire Entrapment/Shelter Deployment Accident Investigation Report

[Entrapment incident occurs on Aug. 12, 2012]

Eight-Member Report Team

Report Length: 30 pages

Stated Purpose: “. . . Identify and determine the key events, deficiencies, conditions, risk factors, and system failures that contributed to the entrapment/shelter deployment. The team’s recommendations were to consist of improvements or preventative measures that could potentially prevent similar future accidents.”

Organization (Chapters): Executive Summary; Investigation Process; Prologue; Narrative; Timeline; Findings and Recommendations; Conclusion and Observations; Maps/Photos/Illustrations; Appendix A – Fire Behavior and Weather Summary; Appendix B – Personal Protection Equipment Report; Appendix C – Acronym List.

Findings and Recommendations: 12 individual “Findings”, each with a subsequent “Discussion” section, followed with specific “Recommendations”.

http://bit.ly/hollowaySAI

Flat Fire Entrapment Facilitated Learning Analysis

[Entrapment incident occurs on July 14, 2012]

Five-Member Report Team

Report Length: 22 pages

Stated Purpose: “The intent of this analysis is to gain an understanding of the conditions that affected the thoughts, decisions, and actions of the persons involved. We intentionally avoid finding fault and placing blame, as this often blocks opportunities to learn from the event. One goal is to use this event to aid firefighters in recognition of early developing situations and allowing firefighters to make decisions that will prevent near misses, accidents, and injuries on future fires . . . The single most important focus of the FLA is to have a facilitated dialogue with the participants of the event to learn why the decisions and actions of persons involved made sense to them at the time . . . It is hoped that firefighters will use the “Event Summary” narrative, the “Lessons Learned” and “Discussion Points” (either stand alone or together as time allows) during safety briefings and training sessions. A sand table can be used to http://bit.ly/flatfireFLA help tell the story . . .”

Organization (Chapters): Introduction and the FLA Process; Chronology of Events; Fire Behavior Forecast for July 14, 2012; Event Summary; Human Performance; Lessons Learned; Discussion Points; IDEAL Lookout; Attachment 1: Emergency Traffic.

Lessons Learned: The “Lessons Learned” section was divided into “Lessons Learned from Firefighters” and “Lessons Learned from the FLA Team”. Both sections featured the same three subject areas: 1) “Preparation and Training”; 2) “Situational Awareness”; 3) “Communications”. This section also included an additional eight follow-up “Discussion Points” for the reader’s consideration.

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2003 Cramer Fire – 2 Firefighter Deaths Conditions Versus Cause “The causes of the tragedy were primarily focused in Earlier, I said there would be more on conditions vs. cause. It may seem like semantics two critical areas: failures in leadership, and overall to some, but—trust me—for many folks this is a real big deal. It’s part of why reports failure by leaders and firefighters alike to respond to a rapidly deteriorating situation (lack of situational can look so different. The other big deal is recommendations or “corrective actions”. awareness).” Stay with me. Cramer Fire Accident Investigation Factual Report; December 2003 When an “Accident” occurs within the U.S. Forest Service, Line Officers have decision power on what type of approach is utilized. More Red Book!: FS – Forest Service Line More Recent Reviews Officers are the deciding officials regarding what type of accident investigation or 2011 analysis method is to be used for accidents or near misses occurring under Forest Service Coal Canyon Fire jurisdiction. 1 Firefighter Death; 2 Firefighter Injuries “The purpose of this document is to promote dialog and These days, this Forest Service Line Officer decision almost always results in an FLA—or learning from the Coal Canyon Fire. It is built on the philosophy that genuine learning is more than a transfer something FLA-like. of information; it is an active process in which you develop your own understanding by personally engaging Here’s what the FLA Guide says about “Cause”: with events and ideas. This kind of learning also involves dialog among people with different Characterize the Accident by Conditions, Risk Factors, perspectives, at different levels in your organization.” or Chance Conjectures—Not “Cause”

“Firefighters on-scene experienced these events from There is a deliberate effort in the FLA process to avoid labeling human errors, multiple points of view. So, part of understanding the omissions, or other actions (or non-actions) as “causal”. Labeling these findings as accident is seeing it from their various perspectives. “cause” impedes our ability to explain or understand what was experienced in Second, you, the readers, have diverse perspectives. You context before the accident . . . are diverse with respect to the agencies you work for, your levels of experience and responsibility, your learning styles, and your specific learning objectives.” Coal Canyon Fire Serious Accident Investigation Report April 2012 There has never been any difference of opinion

2012 on WHY we write these reports. It is to LEARN Steep Corner Fire 1 Firefighter Death as an organization. But the most effective approach “Instead of judging, take the more difficult path toward learning by asking questions as you read this report.” to teaching and learning (two different things, Steep Corner Fatality Serious Accident Investigation Report by the way)—this is what we can’t seem to agree on. January 2013

2013 Yarnell Hill Fire 19 Firefighter Deaths Big Philosophical Differences “This report does not identify causes in the traditional And on “recommendations” or corrective actions, the FLA Guide informs: Our sense of pointing out errors, mistakes, and violations but traditional safety paradigm has been that we prevent accidents by investigating them, approaches the accident from the perspective that risk is discovering the cause, and then fixing the cause to prevent a repeat of the accident. …In inherent in firefighting . . . In this report, the Team tries to many circumstances, recommendations actually interfere with learning. Instead of minimize the common human trait of hindsight bias, which is often associated with traditional accident reviews recommendations, consider ways to make the FLA report an effective and compelling and investigations . . . The Team finds no indication of learning tool. negligence, reckless actions, or violations of policy or protocol.” Big philosophical differences. And this is only in Federal circles. States, local Fire Yarnell Hill Safety Accident Investigation Report Departments, and contractors may fall under completely different standards. [by Arizona State Forestry Division] Sept. 28, 2013 Bottom Line

This ADOSH report identifies “errors” that the Granite The bottom line is as long as there is a drastic difference of opinion on what method or Mountain IHC made on the Yarnell Hill Fire, including: perspective to use, reports will continue to look and feel very different. not having an escape route “scouted, timed, marked or improved;” “not having a lookout when they made the There has never been any difference of opinion on WHY we write these reports. It is to descent to Boulder Springs Ranch;” and not LEARN as an organization. But the most effective approach to teaching and learning communicating to their supervisor “where they were (two different things, by the way)—this is what we can’t seem to agree on. moving and what route they would be traveling.” Granite Mountain IHC Entrapment Maybe different people learn different ways. Maybe organizations learn one way and and Burnover Investigation individuals learn another. All through grade school, I had a variety of teachers who had [by Arizona Division of Occupational Safety and drastically different methods of teaching. I learned something from all of them—just not Health (ADOSH)] always what they set out to teach me. Dec. 4, 2013

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Shop Talk

Do you have a Rapid Lesson to share?

Click this button: Rapid Lesson Sharing RLS

http://bit.ly/llcrls

Rapid Lesson Sharing (RLS) is a method for firefighters to quickly get lessons to the field. Topics might include successes, challenges, a way of accomplishing tasks more efficiently or safely, close-calls—anything others can learn from.

The Wildland Fire Lessons Learned Center (LLC) has received RLS’s on topics including drip torch malfunction, driving at night, communication on medical incidents, falling roadside hazard trees, bucket strikes, and grizzly bear encounters.

RLS guidance can be found in Chapter 18 Reviews and Investigations in the 2014 Interagency Standards for Fire and Aviation Operations (Red Book).

ATV Flipover RLS  An ATV operator on fire patrol in Colorado experiences an ATV flipover. This incident has several important lessons that are important to share with others. How do they do this? Answer: They click the “Share Your Lessons” button (above).

Staff Infection RLS

 A firefighter in North Carolina notices a small bump/sore on his forehead. With each day on the fire, it gets worse. He ends up with a severe staph infection that puts him in the hospital for four days. Several lessons emerge. What’s the quickest way to share them? Answer: They

click the “Share Your Lessons” button.

IHC Pack Out RLS Smoke Grenade RLS While constructing line on a remote wilderness fire, an IHC member  After the Yarnell Hill Fire tragedy, a fire crew notes the twists his knee. A creative makeshift splint (see photo above) and Granite Mountain Hotshots’ reported inability to backboard are used to successfully pack this injured firefighter out. communicate their location to air attack. Several members of this fire crew are military Afterwards, the IHC wants to communicate several lessons with other veterans. They have an idea that they want to crews about being prepared for medical emergencies. They also have share with other crews immediately. What do a short video that they want to share about how their training paid they do? Answer: They click the “Share Your off in this pack out incident. Lessons” button. How do they get this video and their lessons out to you—and others? Answer: They click the “Share Your Lessons” button (above). Check Out These RLS’s—and Many More—on the LLC Website !

If you have ideas on new subjects for this Shop Talk page, please contact: Paul Keller [email protected] 503-622-4861 7

One of Our Own

Photo by Eli Lehmann

Paul Cerda

Insights on Our Challenge to Learn from Reviews

By Paul Keller and Alex Viktora

f you’re new to Paul Cerda’s crew— beware—you’re about to get homework I assignments on incident reports and reviews.

“I use incident reports and reviews in both our formal and informal training,” assures Cerda, Superintendent of the Alpine Interagency Hotshot Crew. “I usually have the crew begin preseason reading assignments in March. Once we have our crew roster built, I start sending out reading assignments—with deadlines.”

Cerda explains that, most often, he uses accident reviews. Often times, it’s not the entire review, but portions that might target themes and topics that he feels will directly benefit his crew. “If there’s validity to getting back to the basics and things like that—or concepts that we’re going to be introducing during our refresher training” he says he’ll spotlight these areas for his crew.

This gent has been around long enough to have Paul Cerda, Superintendent of the Alpine Interagency Hotshot Crew, uses incident reports honed some keen insights and observations not only and reviews in both his crew’s formal and informal training. on wildland firefighting, but also on this country’s wildland fire culture.

“I think it’s also important to review those historic ‘big’ accident reviews—like South Canyon, Thirtymile, and Dutch Creek. We need to remember why our culture is shaped the way it is and why we operate the way we do. I believe it’s based on some of those past reviews and the lessons that we’ve learned from them.”

Never Looked Back Paul started his fire career 18 years ago—in 1996—on the Angeles National Forest. While attending Mt. San Antonio Community College’s fire science program, he became a member of a 20-person Type 2 crew.

“From there I was able to detail onto the Dalton Hotshot Crew—as well as a couple local engine crews,” Paul, 36, recalls. “I guess I made a name for myself. I just kept pursuing this career. I never looked back.” In 2000, he attended the Sacramento-based Wildland Firefighter Apprenticeship Program and graduated from its Advanced Academy the following year.

Next stop: The Big Bear Hotshots on the San Bernardino National Forest, where Paul was a Captain. In the spring of 2008, Paul joined the Alpine Hotshots, based in Rocky Mountain National Park, as the lone Foreman. During that season he was detailed into the vacant Superintendent position. By November of that year, Paul became the fulltime Superintendent.

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[Continued from Page 8] Put Them in the Hot Seat Back to how his crew uses reviews.

“We read them together and go over them as a crew. We use sand table exercises to help educate ourselves—with a special focus on our up-and-coming folks and our mid-level leadership people. We’ll put them in the ‘hot seat’—using the review or investigation report as the framework.”

While this Superintendent is teaching his crew, he is also constantly trying to increase his own learning. Paul explains how, in his own experience, his perspective has changed and broadened through the transitions of his multiple fire seasons.

“I’ll go back and reread reviews—that maybe I’ve already read several times earlier. I’ll try to look at them from a different perspective.” He believes this process represents an important challenge to our culture—to continually look back through different filters as you grow in your fire career.

“And, especially,” Paul says, “when you move into your first level of leadership. It’s Cerda (pictured on right) says he puts his crew members probably good to go back to that report and look at it through a second lens, a into the “hot seat” on sand table exercises—using a review or an investigation report as the framework. second filter. As a captain or unit leader, it’s important to go back and look at it again through a renewed perspective.”

From Blaming to Learning Over the course of the last two decades, this veteran firefighter has seen incident reviews change—he believes—for the better.

“I think our culture has changed from one that

pointed fingers at individuals and organizations to “I think you need to keep it simple. I want my GS-4 firefighter one that, instead, looks at the contributing factors. We’ve gotten away from focusing on the ‘who’ and to be able to read and get something relevant from a review.” now are more concerned with the ‘what’ and the

‘why’. This has helped us to learn. We’ve moved from a blaming culture to a learning culture.”

Paul points out the importance for reviews to be written for the fire culture “so we can learn from the events that led up to the accident.” In addition, he believes that the external audience who reads reviews—the broader public and various outside organizations—tend to not understand our fire culture.

“Our culture is foreign to a lot of these folks. It’s hard for them to understand that we don’t work in a risk-free environment. That while we do mitigate and manage risk to the best of our ability—we do not work in a hazard-free environment.”

Paul summarizes what he believes to be the key practicing philosophy/take-home nugget from reviews.

“We need to try to look at what happened from our peer’s perspective. We need to truly try to learn from the review. It shouldn’t be a witch hunt. It should be a review and a learning process of how the accident happened.”

Mental Slides Paul also has his ideas on how reviews could be improved to be more relevant for the field.

“I think you need to keep it simple. I want my GS-4 firefighter to be able to read and get something relevant from a review.”

He adds that he believes that after reading a review, it’s important for all of us to always be mindful of what happened to those folks in the narrative of that review. After reading the review, Paul emphasizes, you need to strive to be cognizant and aware of when you might find yourself out on a fire with components of that same narrative suddenly surrounding you.

That’s why Paul says it’s critical for his firefighters—and for all of us—to develop

mental slides from these reviews. “So when you get into that situation—or a similar one—you can pull that slide from your tray and say: ‘Oh, you know what? We're not doing that. We're going to sit here.’ Or: ‘You know what? Yes, we are going to reengage and this is how we're going to do it’.”

Cerda believes that it’s critical for firefighters to [Continued on Page 10] develop mental slides from the lessons in reviews. 9

The Alpine Hotshots on the 2012 Pine Ridge Fire near De Beque Canyon in Colorado. Superintendent Cerda is back row, far left.

[Continued from Page 9] Yarnell Hill Last season, Paul’s association with the Granite Mountain Hotshots’ tragedy on the Yarnell Hill Fire was twofold. He was a member of the National Park Service Fire and Aviation Honor Guard, whose duties included presenting the flag, serving as casket guards, and supporting memorial and graveside services at the individual ceremonies. He was also selected to be one of the Subject Matter Experts for the draft Yarnell Hill Safety Accident Investigation Report.

Paul acknowledges the confusion—and debate—over the two reviews/reports that came from this fatal incident. (The previously mentioned SAI released by the Arizona State Forestry Division, and the separate Granite Mountain IHC Entrapment and Burnover Investigation report by the Arizona Division of Occupational Safety and Health [ADOSH]).

He explains that these two reports have confused the fire community regarding what reports should be and what the overall intent—and intended outcomes—are for serious accident investigations.

Paul says he would advise younger firefighters to take both reports as a learning opportunity. “Try not—as hard as this is—to form an opinion. Look at both reports and develop a list of questions that potentially could have led to the outcome.

“I put it back on the employee to read both reports. Not once, but twice. Because it's going to take a couple of times to read those reports and understand who's writing them. Why are they writing it? Try to better understand the difference in culture between the two reports.”

Paul continues, “One of the reports is framed more to how we conducted reviews two decades ago—maybe pre-2000. The other report is framed more toward our current culture. So I think it’s important to take the nuggets out of both of these reports and embrace and brand them into your brain. You need to make sure that you’ve developed the appropriate mental slides.”

And, if you’re on Paul Cerda’s crew, be ready to be inserted into that “hot seat” and utilize these slides in Cerda (center with hazel hoe) believes that it’s an upcoming sand table exercise. Got a potential important for firefighters to read—more than “One of Our Own” candidate? It’s good advice for all of us. once—both of the incident reports that focus on Contact: Paul Keller the Yarnell Hill Fire tragedy. 503-622-4861 [email protected]

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Our Recent Fireline Tragedies and Accidents Prompt Key Question: What Do You Leave Behind?

By Ed Hiatt notification of your accident? Before last season, I never thought am sure many of you have been thinking about the 19 about such things. But when I read the accounts of how some Granite Mountain Hotshots, Token Adams, Luke Sheehy, and members of the Granite Mountain Hotshots’ families were all of the others who did not go home this past season. What notified, everything changed. I did they leave behind? Right now on our unit we are also going to have our folks get They left the memories of what they accomplished, the friends their finger and foot prints recorded. We are going to ask that they made, the fun times we had with them. They also left they list where their dental records are located and how they behind their loved ones. Mothers, fathers, brothers, sisters, can be obtained. Again folks, I am not trying to introduce wives and children, other family members, friends and thoughts that horrify you. But it is important for us to plan for colleagues. So many of us who will miss these people and what each of us leaves behind. On our unit, we have also struggle without them. identified several significant questions that we feel need to be answered: How does one get to Those who are left behind will But when I read the accounts of how some members these emergency contact forms and do their best to move of the Granite Mountain Hotshots’ families were records after business hours, on a forward—without those who notified, everything changed. weekend or holiday? What if your were lost. And all of us still supervisor or holder of the here, what do we leave information is out on a fire assignment? You obviously don’t behind? want your family to have to wait to find out about your fate.

What Have You Left Behind? Yes, I realize this information may contain PII (Personally If one of us is so badly injured or dies in terrible circumstances, Identifiable Information). In the event that someone has an can those who must identify us do so? I am not trying to be unfortunate accident, I believe that we can come up with a morbid here. I am just strongly recommending that all of us need method for getting this information out rapidly. to put some thought and preparation into this. What About Your Will or Trust? How are we identified rapidly following an accident? Again, I am While we are at this, do you have a will or trust? Have you not trying to bring gruesome thoughts into your head. But what updated it? Have you identified beneficiaries to your belongings do we—every one of us—leave behind? For instance, if you are and to your wealth? Those earnings that you have worked so caught up in a fire and you receive serious burns and your fingers hard to accumulate by sacrificing so much time away from your are seriously damaged, how are the authorities supposed to loved ones. And, how do you want your life celebrated? How do identify you? you wish for your remains to be handled?

Several of us in the Southwest Area have discussed this. We are Take some time and give these things some thought. Update now ensuring that our emergency contacts forms are up-to-date. your records. Be sure to leave behind a record of how your loved Are yours? Do they really hold the information that will allow our ones should be notified, by whom and where. Leave your designated contacts to be contacted? records of how you can be identified. Update your records to

How Do You Want Your Loved Ones to be Contacted? identify who will be your beneficiary for what you leave behind.

Do you wish for a designated individual or group to make the Please folks, let’s make it just a little bit easier for those who notice in person? Whom, specifically, do you want to make this may be left behind.

For more info on being better prepared for traumatic events, see the Ed Hiatt is the North Zone Fire Management Officer on the North Two More Chains 2013 Winter Issue: “Taking Care of Our Own” Rim District, Grand Canyon National Park and North Kaibab Ranger http://bit.ly/2mc2013winter District, Kaibab National Forest.

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Your

FEEDBACK

Simplicity and Self-Awareness Refocus on What We Do Tomorrow I work for San Diego Fire-Rescue. I read and enjoy every issue Nice articles on AARs [Fall 2013 Two More Chains], guys. of Two More Chains. As I read your last [Fall 2013] issue I In the past, I've focused on what went right and what went wrong. realized how boring and non-authentic our AARs are. It doesn’t really matter what the incident is: brush fire, structure You taught me to refocus on what we do tomorrow. fire, multi-casualty incident, etc. Jason Greenlee, Director

Most members are afraid to talk about truths for fear of being Fire Research Institute criticized, judged, or stepped on by the B.C. facilitating the San Antonio, Texas AAR. Learning from Each Other The PLOWS acronym is a refreshing take on the AAR and much Thank you for your fall edition of Two More Chains. I always look appreciated. The San Diego Fire-Rescue Department is in the forward to this publication’s arrival. It's a good read—with a number of beginning phases of changing the way our leaders lead. This is informative/thought-provoking articles. a slow process but worth the wait. Our Assistant Chief Brian One of my fire roles—here in Victoria, Australia—is a Divisional Fennessy is leading this change and we are grateful for it. Commander. There are so many similarities to our work across the Travis [Dotson] hit the nail on the head when he talked about world. While I was part of an Incident Management Team for six weeks our need to complicate things and to do it in a hurry [Ground in 2009—fighting fires in British Columbia—I really appreciated how Truths; Fall Issue]. I’m not quite sure where these internal effectively we can work with—and learn from—each other. forces come from, but I do know that if you work on it within Travis Dotson sounds like a very experienced operational firefighter yourself you can improve your ability for patience, simplicity, and a bit of a character. (“Lead up, Tool Swingers” makes me laugh and compassion. every time!) I would like to meet him on the fireline one day! Fully I try to keep these thoughts in the front of my mind (self- agree with his comments on not having to fight the fire head-on all the awareness) on a regular basis—not only when I’m at work but, time. also, when I am at home. This way of thinking has improved We must actively and continuously assess the risks before turning our my clarity of mind tremendously and has improved all of the strategies into tactics. relationships in my life. Brad Fisher, Roading Manager Thank you for a great publication. Gippsland Region, Department of Environment and Primary Industries, Jeff Sallee, Engineer Land & Fire Services, Bairnsdale, Victoria San Diego Fire-Rescue Department Australia

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