How Do We Honor the Fallen?

Facilitated Learning Analysis

Roles of Family and Hospital Liaisons, Standards and Protocols for Honoring Our Fallen Employees

The events described in this Facilitated Learning Analysis occurred in the Southern Region from November 23 through December 23, 2016.

“Do the dollars mean more than honor and dignity?”

“People make decisions from either their head or their heart.”

“I am 90% full of pride and honor to work for such a caring and responsive fire community in the time of need. The other 10% is a feeling of worry that if it happens again that I’ll miss a critical item when I’m asked to stand by a hospital bed or hold a family member’s hand.”

Significant Heads-Up

This FLA chronicles the events of a month-long medical incident that occurred during a significant fire season in the Southern Area. This incident resulted in the eventual death of Ray Rubio, a respected, long-time member of the wildland firefighting community.

While there is no standard definition of what “doing the right thing” is, this FLA’s participants expressed that having a clearly communicated set of standards and protocols related to honoring fallen employees would help define what “right” looks like to employees.

From this FLA’s “What Was Learned” Section

Contents

Tribute…………………………………………………………………………………3 Background………………………………………………………………………….4 1. The Parking Lot……………………………………………………………4 2. That Fall Season………………………………………………………….5 3. The Calls……………………………………………………………………..6 4. The Wait……………………………………………………………………..7 5. The End……………………………………………………………………….8 What Went Right………………………………………………………………….8 What Was Learned……………………………………………………………….9 Areas of Further Inquiry……………………………………………………….12 Incident Organization List…………………………………………………….17 FLA Team Members…………………………………………………………..…18 Appendix A – Agency Comments……………………………………..…..19

To protect the privacy of the individuals involved in this incident, all names other than Ray Rubio’s are fictional.

Tribute

In Memoriam Ray Rubio

Ray Fernandez Rubio, of Redmond, Oregon, passed away Monday, December 19, 2016 at the Grandview Medical Center in Birmingham, Alabama. With family, friends, and fellow firefighters by his side, Ray succumbed to a traumatic brain injury which he sustained the evening before he was to return home to Oregon from a wildland fire assignment.

All who loved Ray are left with a powerful sense of loss and sadness. Many of Ray’s family members reside in his childhood home of Brawley, California, where he will also be deeply missed by close friends.

Ray was proud to have served in the U.S. Army as a paratrooper in the storied 82nd Airborne Division. Ray subsequently worked for the U.S. Forest Service, culminating in a 22-year career as a smokejumper. Ray was admired for his unmatched work ethic. He will forever be remembered as a friend to countless smokejumpers and members of the wildland firefighter community.

Ray was the guy who knew how to fix everything with a multi-tool and duct tape. He made everyone else’s problems his problems and would help you out any time of day. When he saw a problem or work to be done, he attacked the project with all of his force. Whether it was mopping-up a small wildfire in the wilderness, cutting saw line, or packing parachutes at the smokejumper base, Ray’s work ethic was legendary and exemplary.

Late at night after a long day on the fireline, if Ray was not working, he was joking. Then his eyes would sparkle in the campfire light and he would start talking about Mrs. Rubio. Ray excelled as a husband, too. He spoke of his wife in the highest regard, worrying about her being lonely in his absence, laughing about something funny that she did, wondering what she would cook when he returned—and always, always telling us how much he loved her.

Forever

BACKGROUND

1. The Parking Lot

Dan had to work to get it to sink in, that Ray’s wife was now Ray’s widow.

On December 20, 2016, Dan sat in a rental car in a funeral home parking lot in Birmingham, Alabama. Dan was trying to hear voices on a cell phone, voices from yet another conference call. Voices that—this time—could tell him, maybe: “What do we do now.”

He sat in the car with a buddy of his and of his friend, Ray. This buddy was Scott, a firefighter from the helitack base down the road from Dan’s own base. A buddy who was there to help him out in a time of need. Next to him in the car was Janet, who was there as a Hospital Liaison, working through the never-ending paperwork. Janet had earbuds in, tuned into the call, trying not to miss a word.

Ray’s wife sat in the back seat, working to comprehend what was happening to them. Dan realized that he had to shift his thinking of her. Dan had to work to get it to sink in, that Ray’s wife was now Ray’s widow.

Ray was Dan’s friend, often described as a brother, a fellow smokejumper who had shared 20 years together with Dan— in the air and on the fireline.

A Manifestation of Support They were 1,977 miles from their home in Redmond, Oregon. It was five days before Christmas. The arrangements at the funeral home were complete. They were now deciding when to turn the body of his friend to ashes, getting that expedited so they could be home by Christmas. Cremation procedures, Alabama paperwork, death certificates, it was all in order. Although Dan had never had to pay for Death Certificates before.

The call continued as the car left the parking lot. Through the city streets, making their way to the hotel, which had become almost-but-not-quite a home away from home in the weeks they had been waiting since Ray fell. The voices carried on. There had been so many calls while in Alabama. Discussing: Department of Labor, OWCP, bills, arrangements, Albuquerque.

Over the course of the last weeks, these calls had been a comfort to Dan. They were a manifestation of support, from their place in a hospital room in Birmingham through to Atlanta, the Regional headquarters, and then on to Washington DC, and back home. All the people in all the places, they were the Care Team, on the line every day to help them, to make things happen. All of this, every day, as Ray lay in that hospital bed with part of his skull removed, waiting to die.

This time, though, the call was different. And not just because Ray was dead. This was not a Care Call. There were so many lines dialed in, more than a dozen. Regional Foresters. The Washington Office. Each line linking to a room with who knows how many people.

One Final Demob Then it was time for Dan to speak, even though he was now stuck in traffic, on his way to take Ray’s wife—now Ray’s widow—to her hotel. But it would be OK. This was Dan’s zone. All the years moving aircraft and smokejumpers to fires, moving boosters between states. Organizing reinforcements, cargo, demob, and even an occasional medevac. How many times had Ray been one of those Dan had sent moving across the mountains? And now there was one final demob.

The arrangements had been made, with a solid team. Mike back at the Regional Office was a professional. He knew what to do to get the aircraft lined up. Unfortunately, this same thing had been done just two weeks before as another firefighter from the mountain states had lost his life in the South and had to be taken back to those who mourned him. Now the Care Team worked with Dan. Things were taking shape. It was not a surprise. It had been clear in most of their minds that this was coming, that Ray would not recover, and they had set to the task of what to do next.

It was time to get Ray home, with an Honor Guard. And Ray’s widow and Dan were going with him. It was time to leave Alabama.

Dan spoke to those in the car, and to those on the conference call: A Forest Service King Air would take them. It was a good ship, the same ship that had flown air attack above so many fires with Dan and Ray on the ground. The same ship like the ones they spoke to from the jump ship as they negotiated airspace above fires. The Honor Guard would be there, and the fellow firefighters from the nearby Forests and bases. All of them would be there to receive Ray as he returned from his last dispatch.

Nothing had changed, but everything had changed.

Suddenly: A New Reality And then, when Dan was done, more voices came across the line. Questions about flight hours, refueling stops. Mike jumped in and started to answer them. The voices were not talking about Care. Not about comfort for Ray’s widow. Not about honoring the fallen. Now the voices spoke of “least cost” alternatives, completion of comparison forms. Now, after Ray finally had died, this had arisen to shape events. This would decide Ray’s return.

Then the call was over. And then they were in the hotel parking lot. It was surreal. They were still in a rental car, they were still in Alabama, Ray was still dead. Nothing had changed, but everything had changed.

Dan’s training had taught him to orient, then decide, then act. Orienting to this new reality—as delivered at the last moment by the voices on the call—would take some effort. Thinking about new contingencies. They would be sending Ray’s wife home coach. Should she check his remains? Did that mean that the Honor Guard should meet them at the baggage claim carousel? What if the airline lost that particular piece of luggage? What if she tried to carry his ashes with her, and there was no space in the overhead bin? Were we really going to make her fly home holding what’s left of her husband in her lap?

Ray was soon to be returned to them, now a box of ashes. Then it would be time to go. Dan now had a day to figure out what had happened, what to tell her, what to do, how to make things right.

2. That Fall season

That year’s fall season had shaped-up to be a record fire season in the Southern Region. Dry fuels and day-after-day of fire weather had resulted in one of the most intense and prolonged periods of firefighting in recent memory.

Ray’s Oregon jump base crew would often send teams down to the South. Typically, these teams would be involved in prescribed fires, with occasional wildfires mixed in. The trips down South were great assignments. Ray and the other jumpers loved to go. It was a chance to see new parts of the country. They were able to burn in new fuel types and experience new fire behavior. And they got to do it with a band of close friends.

But this season was a little different. The orders for the modules came months earlier than in previous years. This time, they were ordered for suppression, not fuels work. But the lineup was the same: two trucks, tools, eight guys, a capstone to the western fire season. That October, they headed down South to get some good work done.

As their assignment proceeded, everything went well for the group. They got on good fires and provided service they could feel proud about. They served as Incident Commanders and Division Supervisors. They were assigned as sawyers in hardwood fuels that demanded real skills. And they got to run leaf blowers, which is a unique experience for those from out West.

Then, as the Thanksgiving holiday approached, it was time to wind down and go home to be with loved ones. Ray was the crew leader. He made sure that they all had their tickets home taken care of. The tools and rigs were cleaned-up and dropped off for the next crews. It was November 22. They got rooms in a hotel in Birmingham and became ready to get up and fly home the next day. They would be eating turkey in two more days. The crew went out to get one last dinner together. As they finished, they made their way back to their rooms to get some sleep.

3. The Calls

A BLM fire manager, also from Oregon, who happened to be in the Southern Region assisting with the fires, traveled to Birmingham to see how he could help. Within a day or two, people were calling him the “Hospital Liaison”.

A few hours later, a member of Ray’s crew was in his hotel room when his phone lit up. He was getting calls from back in Oregon. Ray’s wife had just been contacted by a hospital in Alabama. Ray was in critical condition. They needed to do surgery to relieve swelling in his brain. She wanted to know what was going on, what had happened. The hospital could not tell her. Ray’s crewmember did not have an answer. He had last seen Ray at dinner.

A few hours later, across the country, Dan, Ray’s supervisor and 20-year friend, woke up and saw many messages left on his phone. It was a jumble of information—and misunderstanding—sorting out who had texted or called whom during the night.

Something Terrible had Happened to Ray A few things were clear. Something terrible had happened to Ray. Someone had found him, unconscious, with injuries to his head. An ambulance had picked him up. The hospital had used the information in his wallet to try to find a number for someone who could tell them who he was, and why he was in Alabama. Ray’s crewmember was now there at the hospital with him.

They were not going to be flying home for Thanksgiving.

Another employee was already in motion, providing support to Ray’s wife. The employee worked in operations and had experience helping families of those who were injured while on assignment. The Wildland Firefighter Foundation was already involved. Steps were underway to get Ray’s wife to Birmingham, to be by his side.

Back in Oregon, Dan spoke with his supervisors and the other overhead at the jump base. It wasn’t clear what to do next. One crewmember was already there with Ray and more help was on the way. A BLM fire manager, also from Oregon, who happened to be in the Southern Region assisting with the fires, traveled to Birmingham to see how he could help. Within a day or two, people were calling him the “Hospital Liaison”.

Back in Redmond, it was decided that Dan would travel the next day to be with Ray. As a longtime close friend of Ray’s, Dan knew Ray’s family. In addition, Dan’s years of experience had given him some idea of what needed to be done. The training center in Oregon had offered a class called “You Will Not Stand Alone”. Dan had not been to it, but at least he knew people who had. He knew who to call for help. Two other smokejumpers were slated to travel to Region 8 the following Saturday for a fire assignment. They bumped-up their flights to travel with Dan and to be with Ray.

They made it to Alabama on Thanksgiving night. By 11 p.m. they were walking through the hospital to Ray’s room. The hospital was quiet, nearly deserted, except for the people there for Ray.

In his bed, Ray lay still, showing signs of severe trauma as well as the emergency surgery that had taken place to remove pressure from Ray’s brain. A crewmember was also in the room. Dan thought that he only looked slightly better than Ray. The crewmember had been through a lot. He had stepped-up admirably to deal with the situation.

Now, this group of firefighters sat in the hospital, trying to figure out what to do next to help their friend—and to come to terms with the fact that their friend might be beyond help.

The “Care Team” The next day, more calls came in. So many details had to be taken care of. Between the hospital and the Agency, the paperwork alone was a full-time job. Dan had been around enough to know that the downstream consequences of getting it wrong could be catastrophic. The BLM fire manager stepped-up to the task.

Ray’s wife was also in need of support. Two people set themselves to accomplishing that job.

More and more calls came in, and more calls went out seeking information. It became clear that some organization was needed for these calls, and one quickly developed. Behind the scenes, the Southern Region was mobilizing a team of expertise. They handled business affairs, invitational travel, OWCP, and answered questions that Dan might not have even known to ask. They arranged a conference call. Soon, people were referring to one of those brought in as the Incident Commander. They were calling her team the “Care Team”.

By the weekend, an operational tempo had developed. Other calls kept coming in. Many were from the crew back home, wondering what was happening to Ray, as well as to those in Alabama trying to care for him. Dan realized that there needed to be another call. He organized a crew call for those firefighters closest to Ray to allow them to have their voices heard and questions answered.

The conference calls became one of the fixtures of the day. Dan knew that the Care Team would be able to afford whatever support was needed, at a level that felt unprecedented. That felt necessary, as the circumstances also felt unprecedented.

As time went by, Ray’s condition did not improve. New scenarios popped-up, each demanding research, with offshoots of even more questions: “Can we find a hospital in Oregon that will admit Ray?” “Even if we can, can he be transported on life support?” “What if he lingers here on life support for months, or years?” “Where can his wife stay?” “How long do we stay here in Alabama?”

At some point, it all felt like a blur, punctuated by the daily Care Call and the call with the crew back home.

4. The wait

The doctor’s prognosis was sinking in: Ray would not likely survive on his own, and almost certainly would never regain consciousness.

Mornings and evenings came and went. People came and went, too. A crew from Ray’s base was assigned to a nearby Forest. They would stop by to visit their friend and his family as they could. These visits became more pressing as it became clearer that Ray likely would not be coming home—and people realized that each time they saw Ray might be the last.

There was also a continual movement of firefighters to and from assignments relating to the wildfires in Region 8. Ray had touched so many people’s lives in his years with the Agency. As those people came through, they too wanted to see Ray and do what they could for Ray’s family and friends. Many also wanted to make sense of what happened. Therefore, there were trips to the site of the accident to help them understand how so unlikely an injury could have occurred.

As the days went by, the cumulative impact on those in Birmingham became greater. It became evident that support would be needed for those who were there to support Ray and his family. They sought out someone trusted in whom they could confide. In response, soon others arrived at the hospital. One person would provide peer support and eventually transition to Hospital Liaison when the BLM fire manager went home.

A member of a Critical Incident Stress Management (CISM) group also came by to offer help. Regional staff from Atlanta came, putting their own business and lives on pause to be with Ray. It had become a long-term incident, and the responders were tiring, and needing to return home to be with their own families. This was occurring as Ray’s loved ones needed increasing support, because the doctor’s prognosis was sinking in: Ray would not likely survive on his own, and almost certainly would never regain consciousness.

After two weeks, Dan transitioned with another smokejumper and returned home to Redmond. He maintained contact with those who stayed in Alabama. By then, Janet had arrived to replace the Hospital Liaison who had replaced the BLM fire manager. As more days went by, more people returned home. The stress was taking a toll on the health and wellbeing of those who stayed. After a few more days, the final smokejumper in Birmingham fell ill. It was clear that he needed to come home, too. Dan arranged travel from Oregon to Alabama to return to be with Ray.

5. The END

As Dan checked in for the return flight to Birmingham on December 17, he saw someone wearing a pair of fire boots in line with him. It was Scott, who was also heading to Birmingham. Scott, who had been friends with Ray for years and worked with Ray on helicopters and smokejumping, was traveling on his own time, of his own accord. Scott was going back to see Ray one last time.

When Dan returned to the hospital, Ray was in a different place. He had been moved from Intensive Care to the Comfort Care floor. Life support had been removed. Ray looked different somehow—shrunken, aged, almost jaundiced. He didn’t look like the person they had known. Janet, the Hospital Liaison, and Ray’s friend Scott, along with Ray’s family members, were all there with Ray.

They all knew that they were now waiting for the end. While the others had said their farewells and returned home, these people who were now in Ray’s room beside him had stayed—to help make the necessary arrangements, to be with Ray’s family. To go to the funeral home. To see the coroner about an autopsy. To select an urn. To arrange for cremation. To provide an honorable return home for the family and for an honorable man who had committed his life to his country and his fellow firefighters.

Ray Rubio died in Birmingham, Alabama, shortly after 5 o’clock on the afternoon of December 19, 2016.

What Went Right

Although we all wish that unexpected situations such as these would not happen, we can learn from and highlight those things that we did right.

The “Care Team” consisted of many staff areas, including: travel, Chief Financial Officer, worker’s compensation, benefits, and aviation. They assembled on daily calls to provide answers and support Ray’s family and the Hospital Liaisons.

 A well-organized and dedicated “Care Team” was assembled to bring expertise from many areas under the leadership of an experienced Incident Commander.

 This Care Team consisted of many staff areas, including: travel, Chief Financial Officer (CFO), worker’s compensation, benefits, and aviation. They assembled on daily calls to provide answers and support Ray’s family and the Hospital Liaisons.

 Hospital Liaisons provided support by:

 Providing the timely completion of all paperwork and forms.  Planning for long-term care.  Working daily with the hospital’s Patient Advocate.

 Family Liaison provided support to Ray’s wife and family by:

 Establishing a daily communication channel back to Redmond for the rest of Ray’s crew.  Building a relationship with the hospital Chaplain.

 Smokejumpers in the module provided peer support and comfort to Ray, his family, and to each other—both in Birmingham and at his home in Oregon. Smokejumpers took care of Ray’s house for his wife while she was with Ray in Alabama.

 Ray’s family and fellow workers were able to visit the site of the accident, which helped provide some closure for them.

 Region 8 employees provided support by stopping in to see Ray and the team members.

 Resources that were needed were procured by the U.S. Forest Service, or its partners.

 A nurse known by the team was brought in as a SME to help explain the doctor’s daily prognosis to the family and liaisons.  A peer support person with previous experience in critical incident stress management was brought to Birmingham.

 The Honor Guard planning was reviewed and requests were prepared for several different options to facilitate quick approval.

 The Wildland Firefighter Foundation provided immediate and caring assistance whenever a gap in resources was expressed to them.

 Smokejumpers and firefighters from across the Agency came together to offer powerful, meaningful, and long- term support for Ray and his family.

 Ray’s friends and coworkers were able to harness the power of social media to provide support for his family

What Was Learned

A. Lessons Learned by FLA Participants

Managing social media early on in the event was critical to ensuring the accuracy of information being shared.

The FLA engaged participants through individual and group interviews.

These interviews included: Family and Hospital Liaisons, Air Base Manager, Jump Base Manager, peer support personnel, Deputy Regional Forester, Regional Aviation Officer, Regional Director of Fire and Aviation Management, Helibase Manager, multiple coworkers of Ray’s, Forest Supervisor, agency Chief Financial Officer (CFO), Financial Policy staff employees, and support personnel assigned to the Rubio incident.

Lessons Shared by Liaisons and Peer Support

 Communications back to home unit personnel were critical.

 The family dynamics required multiple Family Liaisons to be assigned.

 The lines of responsibility and authority were often blurred.

 The lack of Advanced Directives by Ray hindered decision-making by family members.

 There was a need for a mental health provider on the Care Team to offer assistance to those people dealing directly with Ray and his family members.

 There is no defined “end to care” needed by employees who supported Ray and family members in Birmingham.

 The Care Team assembled to assist with administrative functions was invaluable.

 Managing social media early on in the event was critical to ensuring the accuracy of information being shared.

Lessons Shared by Support Personnel

 The Care Team calls were a critical communication tool to ensure everyone was hearing the same thing at the same time.

 A lot of information was shared verbally between support personnel and liaisons that should have been documented in writing to eliminate tasks being overlooked or forgotten. “You Will Not Stand Alone” course  Region 8 had a very good “Unplanned Event Job Aid” that had been curriculum. created in February, 2016 but was not used—or widely known about—when Ray’s accident occurred. This “Job Aid” is meant to assist employees in knowing what to do when a circumstance such as Ray’s occurs.

Lessons Shared by Leadership

 For years, we have used agency aircraft to transport deceased employees and family members home, thinking we were within our lines of authority.

 “There are so many moving parts to every case. What’s going to be the next moving part that jumps up and bites us?”

 Doing the “right thing” is value driven and it’s not always going to be the same thing every time. Expectations for the “right thing” do not align culturally and fiscally.

 The Agency must seek review and approval from the Office of General Council to transport non-federal travelers. Cost comparisons for transportation of the deceased’s remains: Must go with the most economical.

B. Insights from the FLA Team

“In any moment of decision, the best thing you can do is the right thing, the next best thing is the wrong thing, and the worst thing you can do is nothing.”

Theodore Roosevelt

Doing the Right Thing

A common theme from people who were interviewed as part of this FLA was the need to do the “right thing” in honoring a fallen firefighter. It became apparent that doing the right thing is subjective and situational. Here are some quotes from FLA participants that demonstrate these varying beliefs:

“We support our employees and families to the limit of the law—and laws have gray areas.”

“We need to make sure we’re setting the appropriate level of expectations. It becomes difficult when we can’t meet expectations.”

“It’s very difficult to decide what the right thing is. It depends on your perspective. It’s not always clear and obvious.”

“If you’re going to say: ‘We’re going to do the right thing’—make sure you know what this is.”

While there is no standard definition of what “doing the right thing” is, participants expressed that having a clearly communicated set of standards and protocols related to honoring fallen employees would help define what “right” looks like to employees.

The Role of Family Liaisons Given the length of time between Ray’s accident and death, the people fulfilling those roles were challenged to maintain an emotional balance and eventually experienced what was termed “compassion fatigue”.

The Family and Hospital Liaisons performed a critical role with Ray’s family and the hospital. Given the length of time between Ray’s accident and death, the people fulfilling those roles were challenged to maintain an emotional balance and eventually experienced what was termed “compassion fatigue”.

During Ray’s hospitalization, essentially two fellow smokejumpers functioned as Family Liaisons and three employees rotated through as Hospital Liaisons. The close friendships between the smokejumpers functioning as Family Liaisons and Ray made them a logical fit to assign as Family Liaisons because they were known and trusted by Ray’s wife.

Under the circumstances, it was also emotionally draining for these people to be in the hospital day after day. There is a developed training session for Family Liaisons and a unit within the “You Will Not Stand Alone” course that details the duties of the Family Liaison. But until someone is functioning in this role, the full weight of responsibilities and long- term nature of the duties isn’t fully understood.

An observation from a smokejumper who was not involved in Birmingham, but remained in Redmond, was that perhaps close coworker types should be assigned as peer support and someone from outside the unit should be brought in as the Family Liaison.

Areas of Further Inquiry

Agency Cultural Expectations

Over time, the incremental change of the way in which we act can result in normalization of a practice and drift, which in some form can result in unintended cruelty. Fixing the cause does not resolve the crisis or make the problem go away.

From “Mindlessness to Mindfulness” by Ellen Langer [Photo unrelated to Ray Rubio]

We expect those closest to the fallen firefighter to organize tributes. We tell them, explicitly or implicitly, to do what’s right and to expect our support. It should come as no surprise, then, that our employees push the envelope of official policy.

Honoring fallen firefighters with Honor Guards, agency aircraft transport, and memorials has become common practice over time—with no real defining point of what those expectations are, what they are not, and what policy actually allows.

Mostly, we didn’t design our approach to honoring our fallen as an Agency. We allowed it to emerge from the community.

What has brought us to this point? Certainly many of us would recall previous events surrounding the honoring of fallen wildland firefighters. For some it could be the DC-3 flying the deceased firefighters home to their families after the South Canyon Fire that creates the vivid impression. As we evolve and make the path forward, such events shape our community, our imaginations, and ultimately our actions.

Over time, and in line with changing norms and expectations among other emergency response organizations—including structural structure fire departments—the practice around memorials for fallen Forest Service firefighters has grown in ways that often differ from what’s normally provided for fallen agency employees in other fields. Nowhere is this difference expressed in Agency policy, but it’s noticeable in the practice.

Official Agency Policy Becomes Problematic In this context, a strict adherence to policy may appear to be straightforward. For those people who are directly involved in honoring their fallen comrade—someone they have often spent years working with and sharing their lives—it becomes much more important and personal than expertly following policies. We expect those closest to the fallen firefighter to organize tributes. We tell them, explicitly or implicitly, to do what’s right and to expect our support. It should come as no surprise, then, that our employees push the envelope of official policy.

The difference between Line of Duty Deaths and non-Line of Duty Deaths, for example, is important in an administrative sense in determining allowances and benefits. But such a distinction does not matter much to the grieving friends of the deceased. For firefighters, it is about what is right in the context of providing Respect, Honor, and Dignity for the family and the fallen firefighter.

The Wildland Firefighter Foundation (WFF) has been involved with supporting families and firefighters so long and so well that the Foundation has become one of the first phone calls that is made after an accident or fatality occurs. Informing the WFF of a situation such as Ray’s results in an immediate response. The primary intent of the WFF is to provide services to the affected families which cannot be provided by the Agency or in the timeframes required in the particular situation.

In this case, the Wildland Firefighter Foundation already had Ray’s wife traveling to Birmingham while some agency managers were just getting notified of the accident. 12

Inappropriate Travel Accommodations On November 30, one week after Ray’s accident but 16 days before the crucial conference call, another firefighter died in a neighboring state while on a fire assignment and was flown home on an Agency contracted aircraft on December 4.

When it came time to complete a similar mission to return Ray’s remains and his wife, the guidance was that per Federal Travel Regulations, costs for transportation cannot exceed the cost of “Why am I arguing with the Washington Office about how to get Ray home?” common carrier. Family Liaison For those involved with Ray’s “Care Team”, it seemed inappropriate to put Ray’s wife on a commercial flight, in coach, with Ray’s ashes. The Wildland Firefighter Foundation provided a First Class ticket for Ray’s wife for their trip home.

The Evolution of Culture and Policy

 Is there an understanding of the differences between policy and what has become normalized, the culturally expected responses associated with providing Honor Guards, agency flights, memorials, and support to families that could be outside of official policy?

 Are there policies that need to be changed to provide support for fallen and injured firefighters, coworkers, and family members? How can the wildland fire community influence administrative processes that do not meet expectations for providing Respect, Honor, and Dignity?

 Is there ever a case in which Agency leaders would “override” policy—doing something they know is not technically authorized but gets to a desired outcome? Who is in a place to make such a decision and under what circumstances may that occur? When decisions shift away from formal authority toward expertise, how are those decisions communicated?

 Is there an understanding of what actions the Wildland Firefighter Foundation will support, which the Agency has abdicated informally, and which the Agency needs to ensure is provided to families?

 Is there a need to develop a management model for providing the services necessary to support Family Liaisons, Hospital Liaisons, peer support, and the associated needs for logistics, information, and finance?

 Is there a difference between how firefighters and personnel in other areas of the Agency are honored? Is there a difference in how Line of Duty Deaths and non-Line of Duty Deaths situations are addressed?

Reflections from a Peer Supporter

The FLA message should also tell the story that we are, in fact, truly committed to doing right by our firefighters. Oftentimes we will need to adapt and learn as we go. These events when one of our own is injured or killed are dynamic situations. The wildland fire community should recognize that advanced care, family care, and memorial planning, works at a very different pace compared to FIRE. It’s a process that takes patience.

Emotional fatigue and stress are hazards in these situations. Our Agency’s “Can-Do” attitude doesn’t always allow team members to express their feelings and concerns—or provide us tools to cope with our emotions.

Providing Care for Care Givers When an employee experiences a serious, life threatening injury, the Agency provides a Family Liaison and a Hospital Liaison. Dan, Ray’s supervisor and longtime friend and fellow smokejumper, served both as a Family Liaison and a peer. A “Care Team” from many staff areas provided support, answered questions, and guided the Family and Hospital Liaisons with their tasks. Peers and friends from within the Agency were also “just there” to provide support on an unofficial basis.

Ray wasn’t the only casualty. Everyone involved was affected. Service toward a fallen comrade is an honor and a duty. From a mental health standpoint, we can also think of it as a hazardous environment that can inflict long-term injury. As an Agency and as a society, we’re better at recognizing physical hazards and physical injuries than we are at recognizing mental health hazards and caring for those affected.

For more than two weeks between Thanksgiving and Christmas, liaisons lived by Ray’s side, in the middle of family and peer grieving and difficult discussions of life support—taking care of others. They didn’t have time to grieve for their friend because they were focused on providing the best family care and support that they could. Dan continued to be the daily conduit of information back to Ray’s dispersed crew. Others on the support teams and liaisons were also affected by the daily support that was necessary. Many of the team members expressed fatigue at the daily calls when the prognosis was always the same.

Each person reacts differently to stressful situations. Our policy appears to be to tell folks struggling to cope and to contact the Employee Assistance Program (EAP). While EAP provides immediate support (up to three visits), it isn’t structured to provide long-term care.

Key Questions Regarding Family and Hospital Liaisons and Core Team Members For those people providing care and long-term support as a Family or Hospital Liaison, or as a core Care Team member, the FLA Team has developed several questions:

1. Have we clearly defined the role of the Family Liaison(s)?

2. Have we clearly defined the role of the Hospital Liaison(s)?

3. What effects do these assignments have on the liaisons?

4. What is the role of the Care Team?

5. What effects do these assignments have on the Care Team members?

6. If we recognize this exposure as a hazard, how do we care for the caregivers over the short- and long-term?

As the Family Liaison, Dan was tasked to provide emotional support for the family and to deal with the bureaucracy. On a personal level, he was also there to honor and support his friend. These involvements require different skillsets, and sometimes may be in conflict with each other. How do you provide emotional support and have to say “No” to a request? Emotionally, this can magnify the stress that is already being internalized.

Many people beyond Ray, his liaisons, and the Care Team were emotionally affected and drained, too. This fatigue acted out in many ways, depending on individual coping strategies. Some would want to go back to work, others drink, some tried to “suck it up.” Many peers and Care Team members felt devalued by the Agency at the 11th hour, as if they had been hit by a bus. That after almost a month of planning, providing briefing papers, asking questions and feeling as if all bases were covered, a final decision occurred that was unimaginable. This was expressed as a surreal experience. These people were asking themselves: “Did this really just happen?”

Questions for Reflection

 How or should we provide long-term mental health care for our affected employees?

 What is our Agency’s response to these situations?

 How do we name and address the emotional stress in these situations?

 Long-term healing from a mental or emotional strain is outside of our ability to diagnose, but that does not mean that it isn’t there.

 What is the right thing to do culturally? Ethically? Fiscally?

 How do we support Family Liaisons, Hospital Liaisons, Peer Supporters, and Care Team members over the long term?

The mission, as they understood it, was to bring Ray home with honor.

Leadership, Delegation, and Decision-Making

We expect a lot from our leaders, especially in tough times. We look to our leaders to articulate a vision and sense of purpose. Leaders lay out sideboards, communicate intent, and delegate authority. When we must balance risk, choose among competing values, and weigh conflicting advice, we ask those in charge to make and communicate clear choices.

Equally important, leadership has a strong symbolic element. Our leaders lift us up, inspire us, and comfort us when we’re hurting.

The people on the ground, Ray’s support group, experienced and interpreted that December 20 call as a failure in leadership. This final conference call to Dan from the powers-that-be that suddenly had nothing to do with care and compassion and everything to do with rules and regulations concerning “least cost alternatives” for returning Ray’s ashes to Oregon. “I felt like I was thrown in front of a bus.

These people close to Ray on the ground had been planning for a It was life-changing, honestly.” month how to get Ray home on an Agency aircraft. They’d monitored and managed aircraft and pilot availability. They’d planned multiple “Is it all about the money? That was a scenarios—ranging from what it would take to bring Ray home on life dagger in my heart.” support to the width of the doorway needed to accommodate a casket Care Team Member without tilting it too much. These are not easy conversations to conduct, especially when everyone is still hoping for a miracle.

These people on the ground had coordinated with Honor Guard contingents on both the sending and receiving ends. All of this planning included daily conversations among a “Care Team” representing multiple disciplines and Line Officers from across the Agency.

The mission, as they understood it, was to bring Ray home with honor. They knew that it would cost more than travelling commercially. The Agency had already spent far more than that on support and care for Ray and his loved

“How did we screw it up? We had a month to get this right.”

Care Team Member

The time for that decision is not in the moment, at the 11th hour, with a single fallen firefighter serving as the test case, on a call with dozens of people, including the Family Liaison in a car with the widow. ones. And they were secure in the knowledge that the same thing had been done successfully before many times for many years—including earlier that same month from another fire in the Region.

To hear, now, with the planning practically complete, that a long-standing practice intended to honor employees was not appropriate was interpreted as a betrayal. We attach meaning to these kinds of events.

The interpreted meaning attached to that call on December 20 by some participants included: “We don’t really care about our fallen firefighters,” “Life First is just lip service,” and “Dollars mean more than honor and dignity.” None of which, of course, reflects the intent of those on the other end of the call.

From the standpoint of the Chief Financial Officer, the rule—the Federal Travel Regulation—is quite clear. They have confirmed this with the Government Services Administration and the Office of the General Counsel. With few exceptions, the Agency simply does not have the authority to use Agency aircraft to transport people or remains when contract carrier flights are available and less costly.

There may be cases in which Forest Service units have not followed these government regulations, but that does not excuse it. Unfortunately, we are not following a consistent or equitable approach from one employee to the next.

Managing and Communicating Change Unlike many decisions in government, we aren’t talking about a change in a rule or policy itself. The Federal Travel Regulation has been around for a long time. This may lead us to miss the significance of a change to the organization. The change here is perhaps in the understanding, application, and interpretation of the rule, and certainly in the long- standing and accepted practice in the field and among firefighters.

Flying fallen firefighters home in Forest Service aircraft has been a norm, practice, and expectation in the community over decades. It’s symbolically charged. It’s attached to honor, dignity, respect, and how we communicate that we care. So changing that practice is a significant organizational change. It is a leadership challenge, requiring: “I tried for 18 years to do  Clear and positive intent from the Chief; the right thing and the  A message that connects with Leadership Stance and values (the “Big Why”); right way.”

 Engagement of affected employees in crafting a “new normal”; and Care Team Member

 A plan and schedule for implementation.

If the Agency wants to adopt a program for transporting firefighters home that’s more like the military’s “We Can”. It may indeed be the right answer. We need to think it through and make that decision deliberately, and together. The time for that decision is not in the moment, at the 11th hour, with a single fallen firefighter serving as the test case, on a call with dozens of people, including the Family Liaison in a car with the widow.

Delegation and Decision-Making Who made the decision that Ray must be transported home on contract carrier? It’s hard to say. It’s hard to say that any “decision” was ever made formally at all. The Chief Financial Officer (CFO) gave a strong explanation of regulations. The Regional Foresters and the Care Team heard that direction and followed it. The ensuing discussion centered on the cost comparison and next administrative steps. Nobody really stepped forward and took responsibility for a change in direction. Perhaps nobody on the call was really in a place to do that.

It’s not clear that any single person had the responsibility and authority to communicate a clear leadership message and intent—to synthesize the information and articulate a choice and a rationale. So nobody did.

In the fire world, delegations of authority provide Incident Commanders the direction and authority to take action. That authority flows clearly through a chain of command. An experienced Incident Commander was assigned to Ray Rubio’s care, and was facilitating the Care Team call. In the non-fire world, delegations of authority are provided primarily through Forest Service Directives. Three members of the National Leadership Council—senior agency administrators— were on that call on December 20. The Regional Foresters have line authority over the aircraft. The CFO has line authority over use of Agency appropriations. The Incident Commander had not been given any formal delegated authority and operated more as a Care Team Leader to provide coordination and support for Ray’s care. It’s not clear that any single person had the responsibility and authority to communicate a clear leadership message and intent—to synthesize the information and articulate a choice and a rationale. So nobody did.

Questions for Reflection

 How do we recognize when we are approaching something on the fly with big organizational and cultural impacts?

 How can we effectively alert each other when a change is “significant” for the organization?

 How do we manage communications? Who should be in the room, and who shouldn’t be? How and when do we communicate direction and organizational change?

 Who has authority to make decisions like this? Who has leadership responsibility to

communicate the decision?

 How do we prepare and train our employees to take on critical roles that may possibly impact their physical and mental wellbeing?

 When are we going to engage all deputy area leadership and employees in discussions of honoring all of our employees, not only Line of Duty or not only those engaged in fire?

Incident Organization List

Birmingham, Alabama . Family Liaisons . Hospital Liaisons . Peer Support personnel . Line Officer representative Care Team (Atlanta, GA; Washington, DC; Albuquerque, NM; and other virtual locations) . Incident Commander . Incident Business Specialist . ASC Office of Workers Compensation . CFO, Budget, Finance and Operations Travel Branch . CFO Budget and Finance Travel Compliance Branch . ASC Benefits Branch . CFO Financial Policy . Washington Office Business Operations . Safety Officer . Aviation Officer

fla team members

Team Lead Jerry Ingersoll Forest Supervisor Siuslaw National Forest

Subject Matter Expert Colby Jackson Smokejumper Missoula Smokejumpers

Subject Matter Expert Jamie Parker Deputy Branch Chief, Incident Business Practices WO, Fire & Aviation Management

Subject Matter Expert Paul Poplett Assistant Director, HRM Centralized Operations & Policy HRM Albuquerque

Subject Matter Expert Steve Rawlings Fire Operations Specialist Region 6 State & Regional Office

Subject Matter Expert Don Walker Deputy Forest Manager Savannah River

Appendix a – Agency Comments

The content in this Facilitated Learning Analysis report for Ray Rubio is related to the ongoing actions of an interdisciplinary working group that has been in the process of updating Agency-wide guidance regarding serious and fatal injuries.

As a result, this working group will address the following items, which have been identified as Agency priorities:

 Develop an action plan that reviews and revises, as necessary, current policy regarding serious and fatal injuries;

 Ensure policies support all employees and their families;

 Address differences between Line of Duty and non-Line of Duty incidents; and

 Develop a strategy for preparing and training employees to serve as Agency liaisons.

The working group will be expanded to include representatives and Line Officers from the field. Currently, the working group includes those from: Financial Policy; Travel Operations; Travel Compliance; Workers’ Compensation; Pay and Benefits; Fire and Aviation Management; Law Enforcement; the Office of Safety and Occupational Health; and Acquisition Management.

We expect these ongoing efforts to help us make more informed decisions in supporting our employees and their families.

Forest Service