Fire Siege of 2003 Safety Protocol Review Pacific
Southwest Region
Fire Siege of 2003 Safety Protocol Review Pacific
Southwest Region
Team Leader Pacific Southwest Region
Ed Hollenshead National
Fire Operations
Safety Officer
John Wendt
Six
Incident Commander Type 2
Dan Felix Fire
Behavior Analyst,
Matt Kingsley Aviation
Safety,
Bureau
of Land Management
Jerry McGowan Safety
FIRST Chair,
Pacific
Southwest Region
Gary Thompson Fuels
Staff, Pacific Southwest
Region andWriter/Editor
Sally Haase Fire
Research,
Pacific Southwest Research Station
Peter Tolosano Regional
Fire Safety Officer,
Pacific
Southwest Region
The
Interviews conducted for the review revealed an impressive commitment to safety as the fundamental principle of fire operations. The core values of safe fire operations were clearly reflected in a strong, disciplined commitment to compliance with the Standard Firefighting Orders, and recognition that the 18 Watch Out Situations be addressed whenever and wherever they arose. The firefighting organization, regardless of jurisdiction, was behaving and operating in a safe manner and was effective in meeting agency and most public expectations regarding safe and effective fire suppression.
Suppression of these fires began before ignition. Steps taken prior to the fires to prepare citizens, communities, and emergency response personnel from other agencies were important subsequent contributors to public and firefighter safety. The presence of highly seasoned personnel from different agencies and jurisdictions, most who were known to one another, clearly contributed to the safe and effective operations conducted during the awkward, chaotic hours and days following initial attack.
Prescriptive safety policies, such as the 2-to-1 work/rest guidelines, are forcing fire leadership to violate or risk violating protocols to complete the emergency response mission and meet agency expectations for the protection of lives and property. Those interviewed reported that strict adherence to prescriptive policies would have diverted critical attention (diminished situational awareness) and energy from accomplishing incident objectives in a safe and efficient manner.
Policies can be improved to define acceptable risk and the decision space available to the field commanders and fireline supervisors. The reality on the ground requires fireline leadership to exercise initiative in meeting agency and public expectations within the confines of a broad, yet sufficiently specific and focused intent relating to performance expectations and firefighter safety, and that the individual recognizes and accepts responsibility for his or her own safety and performance.
We must continue to
reinforce a culture wherein leaders understand their responsibility to provide
clear intent, and fireline supervisors exercise prudent initiative in meeting
that intent in a safe and effective manner.
The Review
Team extends a special thanks to the personnel on the
The Team also
thanks the many individuals who took time from their busy schedules to be interviewed.
The majority of our findings and
recommendations were drawn from these conversations and observations.
Finally, the Team is indebted to Wendy Yun who coordinated
the edits and prepared the final report.
Tradeoffs are Made, Rules are Adjusted
Managing Fatigue of Firefighters
Qualifications of Incoming Resources
On-Scene Safety Inspections by Incident Commander
Entrapment
Avoidance Training and Shelter Deployment Protocols
Appendix A: Personnel Interviewed
Appendix B: Interview Questions
Appendix C: Letter of Delegation and Review Charter
Prompted by a field trip and on-site discussion of
the Southern California fire siege of 2003, the National Leadership Team asked
Regional Forester Jack Blackwell to review fire operations during the early,
most perilous stage of those fires and report back to the National Leadership
Team during the summer, 2004, meeting with any recommended changes to improve
the safety of fire suppression operations.
Much of the National Leadership Team’s discussion
of fireline safety stemmed from the field trip presentation by Randy Clauson,
Division Chief on the
Clauson reported that he found himself in local,
unified command with one other Forest Service chief officer and two local fire
chiefs. Their resources were limited to
those on hand, and though there was radio communication, the four on-scene
commanders were largely physically and functionally separated from the Incident
Management Team (Type 1) that had assumed responsibility for the fire.
Clauson and his colleagues skillfully performed
structure protection and community defense, which probably saved several
thousand houses and an unknown number of citizens’ lives. Clauson and his colleagues identified the
need for and initiated burnout operations along Highway 18 to prevent the fire
from moving into
Clauson asserted that safety protocols had to be
adapted, adjusted, or broken to achieve the desired result of protecting
communities and lives. He concluded that
it would have been impossible to follow all guidelines to the letter and
accomplish what he and his colleagues did.
Clauson’s experience was not unique, and similar situations developed
during the initial stages of the Cedar Fire on the
The Highway 18 operations were highly successful. Those who initiated the operation, Randy Clauson, Jim Ahern, George Corley, and Bill Bagnell, are receiving the Secretary of Agriculture’s award for heroism and emergency response. The danger faced during the early phases of the fires was real, as was the potential for an adverse outcome had skillful decision-making and judgment not been exercised.
Our firefighters are expected to act with uncompromising regard for their safety, and to incorporate all important incident activities into the command and control of the Incident Management Teams that have been delegated authority and responsibility to manage the incident. Firefighter and public safety, as well as organizational efficiency, rely upon good communication, close coordination, and shared objectives. Any real or apparent violation or weakening of safety protocols is potentially serious because of the possibility of tragic, avoidable consequences to those involved.
In this review we sought answers to four questions:
A Safety Protocol Review team, under a letter of delegation (Appendix C) from Jack A. Blackwell, Pacific Southwest Regional Forester, was directed to examine the actions taken during the Southern California Siege of 2003 in relation to safety protocols and to focus on the following three suppression actions:
The review team was directed to make recommendations, where appropriate, for improvement in the application of the following safety protocols:
· 10 Standard Firefighting Orders
· 18 Watch Out Situations
· Lookouts, Communication, Escape Routes, and Safety Zones (LCES)
· Work/Rest Guidelines
· Policies resulting from the Thirtymile Hazard Abatement Plan
· Interagency Driving Regulations
· Interagency Helicopter Operations Guide (IHOG)
During the
fall of 2003, while under the influence of mild
During their
initial phases, these incidents were characterized by rapidly evolving initial
attack on multiple ignitions in a multi-jurisdictional environment that
escalated to Type 1 complexity while being managed locally with Type 3
organizations. The transition, from initial
attack through extended attack to Incident Management Team assumption of
responsibility, was a time of peril to property, the public, and firefighters. There was a heavy reliance on local firefighting
resources operating within the framework of their mission while attempting to
prepare for and assign incoming non-local resources.
The Strategic Decision and
Assessment Oversight Review – Southern California Geographic Area concluded:
“The nature of the incidents precluded many of the
mandated actions without disengagement of resources actively involved in
protecting civilian life and property.
The fires moved rapidly from one agency jurisdiction to another,
including tribal lands and communities.
They were attacked by a variety of local government agencies across multiple
jurisdictions. Rarely have fires moved
into and out of so many jurisdictions so quickly.
The inability of Federal fire managers to follow all of the Thirtymile
policy requirements were troubling to them and added yet another layer of
concern to an already stressful situation.
Managers made conscious decisions to modify or delay implementation of
some of the requirements since interrupting operations would have endangered
many more private citizens, their homes and whole communities.”
The review team interviewed personnel with key roles in the incidents and referenced several reports covering various aspects of the Siege of 2003. Findings, conclusions, and recommendations were identified and jointly agreed to by the review team.
The review team met over a three day period with selected individuals who were responsible for decision-making. Those interviewed were asked to discuss their role and the sequence of events relevant to their involvement in the aforementioned suppression actions. A series of questions, provided by the review team (Appendix B), was given to each at the time of the interview to stimulate and focus the discussion on safety protocols and their relationship to the interviewed firefighter’s actions. The period of time reviewed included initial attack through the conclusion of the most active fire spread. The purpose of the interviews was to assess commitment to public and firefighter safety, and adherence to agency protocols intended to assure public and firefighter safety.
Several reviews and reports have been completed on the Siege of 2003. The team referred to these reports, where appropriate, to supplement the synthesis of comments by those interviewed. The reports include:
1. Strategic
Decision and Assessment Oversight Review –
Prepared for the Pacific Southwest Region, Southern
Operations Geographic Area Coordination Center (GACC), the report examines
management actions of all incidents that occurred in October and November of
2003 within
2. Lessons Learned Report (http://wildfirelessons.net/) Southern California Firestorm 2003,
Prepared by
the
3.
R5-FAM-BOD Safety
Group Report, Pacific Southwest Region – Fire, Fuels, and Aviation
Management.
Prepared by the
Pacific Southwest Region Fire and Aviation Management Board of Directors, the
report identifies safety concerns that were unique to the Siege of 2003.
The team identified
three broad themes affecting safety on fireline operations for both the Old and
Cedar fires. The first concerned
decision-making before and after the fires started, which contributed to a safe
working environment for fireline operations.
The second concerned safety as a core value, which was symbolized as
adherence to the Standard Firefighting Orders and response to the 18 Situations
that Shout Watch Out. The last concerned
decisions that were made to modify, adjust, or hold in abeyance specific protocols
and safety policies so that local fire managers could operate safely in a
situation of great peril. We identified findings,
drew conclusions, and proposed recommendations for each theme.
The results of the interviews encompassed all but two
of the safety protocols--interagency driving regulations and Interagency
Helicopter Operations Guide--the team was asked to address. Neither was mentioned as a safety concern during
the interviews.
Suppression of
these fires began before their ignitions.
Substantial, impressive work with communities aided operations and
contributed to success on the
The Incident Commanders on the
fires made strategic decisions based on threat to human life and property,
delaying, modifying and sometimes abandoning strategies (such as perimeter
control) until higher priorities were met, (Strategic Decision and Assessment Oversight Review – Southern
California Geographic Area).
Once the fires began, local Incident Commanders found themselves with
initial attack and Type 3 incident management capabilities, but with Type 1
incidents of exceptional ferocity and danger to manage. Community protection, evacuation and the
protection of public and firefighter safety became dominant concerns for the
local resources and on-scene Incident Commanders. Initiative and resourcefulness were common
virtues, though Incident Commanders were concerned that they would be harshly
judged for their decisions in adapting safety protocols to meet local
emergencies.
Planning Prior to Ignition Contributes to Safety. Involvement of line and staff officers prior to the incident, development of cooperative,
interagency relationships, and participation in community preparedness planning
were key elements to operational success in the protection of threatened communities. The Mountain Area Safety Taskforce involving
the
Interagency relationships developed prior to the fire contributed to the
successful evacuation and community defense actions taken during the dangerous,
early stages of both incidents.
Coordination between local Sheriff’s Departments (
Initial Attack and Type 3 Organizations Deal With Type 1 Incidents. The initial attack Incident Commanders were seasoned firefighters from several agencies, and they quickly recognized that the complexity of these incidents surpassed their capabilities. They ordered resources and requested Incident Management Teams. The Southern California Geographic Area Coordination Center set in motion an unprecedented mobilization of Incident Management Teams, as well as firefighting and support resources. As these resources were being built up, initial attack forces remained engaged in fire operations. Local decision-making adjusted to rapidly changing circumstances. Local commanders focused on critical objectives, including safe fire operations, the protection of lives, and the protection of communities.
During the early stages of the fires, community protection needs were immediate and rapidly changing. Local government and agency personnel planned, implemented, and maintained operational tactics that were communicated to, but not directed by, Incident Management Teams. Incident Management Teams were beset with confusing conditions: which resources were assigned, where they were, how to prioritize short- and long-term objectives given the fires’ threats, and how to effectively deploy resources as they became available were all questions faced by the Type 1 Incident Management Teams. This confusion hampered the formulation and implementation of a comprehensive, coordinated approach to overall incident management.
Local Incident Commanders Exercise Initiative. Those who assumed the responsibilities of local Incident Commanders did so as a consequence of qualifications and availability. In the case of Highway 18, some with whom we spoke revealed misgivings about the assignments and direction given to them by the Type 1 team. Communication and collaboration were impaired because, with the escalating fire conditions and mounting losses, key representatives of involved agencies, administrators, and stakeholders could not be assembled for conventional, face-to-face meetings. The threat posed by the Old Fire during its early stages, therefore, allowed for neither the full institution of organizational structure nor appropriate inter-jurisdictional involvement at all scales of command and control.
Local Incident
Commanders performed in dangerous, challenging operational environments on both
fires. Their attention to the task was
accompanied by concern they would ultimately be judged by others--others not
burdened with the responsibility of safely achieving fireline objectives--on
the basis of their compliance with safety rules, regulations, and guidelines. This sense of responsibility exists on all
incidents; however, the magnitude of these
Throughout the ordeal, individuals at all operational levels never lost sight of the number-one priority to protect the lives of firefighters and the public. The decision environment was shared between on-scene incident management, unit management including Line Officers, upper level fire management, and dispatch coordination. Challenges included the need for: a) prioritization for evacuations, b) additional resources and unified command, c) a shift from perimeter to point protection, d) assurance of organizational flexibility, and e) maintaining command and control of dispersed resources.
The capability to directly demand and enforce compliance with the Standard Firefighting Orders and respond to the Watch Out Situations resides with the crew and module supervisors. Setting expectations, providing oversight, and ensuring accountability are responsibilities of Incident Commanders. Those interviewed concluded that some of the policies resulting from the Thirtymile Abatement Plan require that enforcement, instead, be the personal responsibility of the Incident Commander. They further observed that in recent years the agency has instituted guidelines and policies that, at times, seemed to be irreconcilable with the urgency of fire operations and agency expectations for Incident Commander performance. The burden imposed by these increasing agency expectations constitutes a disincentive to serve or acquire qualifications as Incident Commander.
We concluded that in several cases, Type 3 Incident Commanders were engaged in activities conventionally associated with Type 1 incidents without the benefit of Type 1 command and support. Under such circumstances, local Incident Commanders concluded that all safety protocols could not be followed to the letter, but the intent of providing for safety was a primary concern.
· Reinforce and reward prior planning for community preparation, evacuation, suppression planning.
· Reinforce the need for developing strong, local relationships across jurisdictional lines for emergency response commanders.
· Continue to update and streamline local area pre-suppression plans and delegations of authority to include processes necessary to integrate community-based organizations and activities into the command structure of incoming Incident Management Teams.
· Ensure mobilization protocols provide for adequate local knowledge and capability to manage emerging incidents, provide interagency coordination, and maintain oversight that spans transitions of command to Incident Management Teams.
· Provide expectations for Incident Commanders that better align responsibilities with the authority and practical means to meeting them. Reconcile the disparity between agency expectations for Incident Commander performance (safe, efficient, and effective fire suppression) and prescriptive regulations, policies, and guidelines.
· Be clear about whether local discretion is provided to Incident Commanders to comply with the safety protocols.
Without exception, we were confronted
with an impressive commitment to safety as the fundamental principle of fire
operations. By far, the Standard
Firefighting Orders and Watch Out Situations dominated the interviews and were
expressed as the cultural values of every firefighter and manager we interviewed. Some firefighters expressed their concern
that they would be perceived as having “broken” or “bent” the Standard
Firefighting Orders. They were asked
clarifying questions, and the team concluded neither the Standard Firefighting Orders
nor the Watch Out Situations were ever abandoned or ignored. For example, local incident managers grouped out-of-area
resources unfamiliar with local weather and its influence on fire behavior with
local forces. Communications were
complicated by terrain and the occasional non-local resource with incompatible
radio equipment, in which case face-to-face contact was specifically attempted
when radio communications could not be established. Finally, those interviewed asserted that extreme
fire behavior potential was addressed with appropriate evolving, strategy and
tactics with safety a fundamental principle for operations.
The Standard Firefighting Orders shaped
local decisions. The Watch Out
Situations were used to heighten situational awareness and stimulate the
development of risk mitigation and issue resolution. These firefighting tenets were foremost on
the mind of those interviewed. The
Standard Firefighting Orders and Watch Out Situations, therefore, formed the
“line in the sand not to be crossed” for all operations and under all
conditions encountered before, during, and after this siege.
The core commitments to safety are
symbolized by respect for the Standard Firefighting Orders and recognition of
the Watch Out Situations.
Fire managers
communicated clear expectations that firefighters would remain engaged while
houses were burning and lives were at risk.
At the same time, they insisted that fireline supervisors adhere to the
Standard Firefighting Orders and mitigate Watch Out Situations as they occurred
and were recognized. The initial letter
of delegation from the Forest Supervisor to the Incident Management Team
(letter dated
The expectation that
fireline leaders were exercising initiative, performing according to training,
and providing oversight on adherence to Standard Firefighting Orders and
mitigation of the Watch Out Situations was fulfilled. Incident Command relied heavily on fireline
supervisors to recognize situations and act appropriately in view of the
situation at hand.
As has been the case
since changes were made more than a decade ago, the Watch Out Situations do not
include the pronoun “you.” Some we
interviewed expressed concern that this wording had the effect of reducing
personal responsibility for maintaining situational awareness and exercising
appropriate judgment.
Adherence to the Standard
Firefighting Orders and mitigation of the Watch Out Situations by fireline
supervisors was viewed as non-negotiable.
The core value, the “line in the sand”, was to keep people safe.
Excluding the pronoun “you” from the Watch Out Situations has created a situation where individuals are relegating their personal responsibilities to their leadership.
The benefits of training
across agency boundaries are not confined to sharing technical skills, but
foster the development of confidence in the skills and capabilities of
individuals to assist one another through exposure to and mutual acceptance of
firefighter safety as a core value.
·
Continue
to reinforce the Standard Firefighting Orders and Watch Out Situations as the
fundamental core values for the fire suppression organization. Provide for integration into all fire-related
training, planning, and operational execution.
·
Work
with the National Wildfire Coordinating Group (NWCG) to reinsert the pronoun
“you” and thus re-establish the emphasis of the Watch Out Situations as a
personal responsibility to continually assess and recognize the need to adjust
strategy and tactics (situational awareness, risk identification and
mitigation).
·
Continue
local efforts to train across agencies with an emphasis on reaching a common
understanding of the core values and commitment of each agency to the safety of
firefighters.
The checklists, protocols, and prescriptive policies intended to ensure safety could not be entirely implemented without sacrificing performance in the effort to protect life and property. Several of the prescriptive protocols would have distracted fireline commanders and dismissed situational awareness and command effectiveness if they had been followed to the letter.
There were elements of suppression
response and mobilization that created concerns and contributed to the level of
stress of those interviewed. There was
stress associated with attempting to comply with policies, including those
associated with the Thirtymile Abatement Plan, which could not be easily
reconciled with core values or came at the cost of infringing on a core
value. Of particular note were those
policies not seen as adding immediate value to the safe and effective
performance of firefighters during these extraordinary conditions, and the team
also sensed confusion concerning the wording and interpretation of intent of some
policies.
The policies are listed in approximate
order of their frequency as mentioned by the people interviewed.
Policy – Interim
Directive 5130-2003-3; 5130.45-5–“ Incident Commanders have the authority and responsibility
to address fatigue in firefighters and other fire suppression personnel and
ensure compliance with work/rest and length of commitment guidelines.”
NWCG HB2 (Interagency Incident Business Management Handbook) section
12.7-1 – “Work/Rest Guidelines: To
maintain safe, productive incident activities, incident management personnel
must appropriately manage work and rest periods, assignment duration, and shift
length for crews, overhead personnel, and support personnel. Plan for and ensure that crews, overhead
personnel, and support personnel are provided a 2-to-1 work-to-rest ratio (for
every 2 hours of work or travel, provide 1 hour of sleep and/or rest). The Incident Commander or Agency
Administrator shall document, approve, and include in the daily incident
records, the justification for work shifts exceeding 16 hours, including travel
time, after the first operation period.”
Fatigue was managed on these incidents, although not
strictly according to work/rest guidelines. State and local government partners have not
adopted the NWCG Work/Rest guidelines. Example:
72 hour shifts were authorized by the
We confirmed that incident management personnel, ranging from module
leaders to Incident Commanders, were keenly aware of the need to manage
firefighter fatigue and did so as opportunities were presented. Rest was situational and based upon the need
for and condition of the resource. Fatigue
countermeasures were planned and implemented that conformed with the intent of
the policy if not to the letter of the policy.
In every case, there was clear recognition of the need for rest, and
actions were taken to provide for and manage firefighter fatigue during these
difficult times. However, there was
palpable tension between the effort to manage firefighter fatigue and the
recognition that strict adherence to the content of the work/rest policy was
impossible in this situation. While conscious
decisions were made to violate the letter of the work/rest policy, close attention
was consistently being paid to implement the intent of the policy.
Moreover, the guidelines direct that Incident Commanders and Agency Administrators
document work/rest schedules, approve work shifts that exceed 16 hours, and
include the documentation in the daily incident records. Creating and maintaining this level of
documentation simply could not have been done during the initial stages of
these fires, and would have served little purpose.
Local fire chiefs shared with us the impracticality of abiding by the
work/rest guidelines. Where choices had
to be made to either protect their communities or follow the 2-to-1 work/rest
protocol, these individuals elected to meet their jurisdictional
responsibilities for protection as they understood them to be. They strongly encouraged that we revisit and
modify our guidelines to incorporate more flexibility.
The nature of these
incidents did not allow compliance with the letter of work/rest
guidelines. Attempting to withdraw
resources from their assignments while they were still performing safely and
effectively would have permitted intolerable consequences for community
protection, the lives of the public, and to firefighters.
·
Encourage
the National Wildfire Coordinating Group to refine work/rest guidelines to require
initiative be exercised by on-scene managers, who are responsive to the
situation at hand, to actively manage firefighter fatigue.
·
Emphasize
the desirable goal of the 2-to-1 work/rest ratio and 16-hour maximum duty
day.
·
Emphasize
quality rest versus extended rest.
Policy – 5130.45-7 – “Incident
Commanders have the authority and responsibility to ensure arriving ground fireline
resources on Type 3, 4, and 5 wildfires have positive and documented contact
with appropriate incident management personnel to address the briefing
checklist elements in the Incident Response Pocket Guide prior to commencing
work.”
Briefings were delayed for the first 3 to 4 days for
many personnel on the fires. Field
supervisors conducted briefings in the field to the best of their ability,
based on the information they were able to obtain. After that time normal briefings were held, as stated in the Strategic Decision and
Assessment Oversight Review (Southern California Geographic Area Report, USDA
Forest Service Pacific Southwest Region, 2004).
Briefings were performed to provide critical information to on-scene and in-coming resources. Briefings did not necessarily follow the “Briefing Checklist,” nor were they all documented.
“Positive” contact was interpreted to require “face-to-face” contact by the Incident Commander.
There was some
difference of opinion regarding what constitutes a briefing with reference to
the “briefing checklist” included in the Incident Response Pocket Guide.
There was an
across-the-board effort to brief incoming strike teams and resources. At times this meant relying on the resources’
assigned fireline supervisors to perform the necessary briefing. The situation simply did not allow for all
briefing checklist items to be covered or for documentation of all contacts
made and instructions given.
Modify FSH 5130.45 to read:
To ensure arriving ground fireline resources on Type 3, 4,
and 5 wildfires have positive and documented contact with appropriate
incident management personnel to address applicable
elements included in the briefing checklist elements in the Incident
Response Pocket Guide prior to commencing work (FSM 5108). (Note:
New wording is in bold and underlined text.)
Our review
confirmed the findings of the Strategic Decision and Assessment Oversight Review
–
· Establish limits on the number of senior fire personnel from any single national forest that may be assigned to a particular Incident Management Team.
· Establish guidelines for Forest Supervisors to use in determining critical drawdown levels of senior fire personnel and clarify responsibility to make such determinations as local, regional, and national conditions change.
· Clarify instructions and guidelines to Incident Commanders as to when it is appropriate and prudent to turn down a team mobilization order.
· Direct the Geographic Area Coordination Centers (GACC) and Regional Offices to establish parameters of program leadership drawdown. Develop management action points that would indicate a need to change team rotation; e.g. order an Incident Management Team from outside the region in order to reduce the impact to affected forests.
Policy – from National Mobilization Guide (March 2002 – sec 13.1) (March 2004 – sec 13.3), “Dispatch centers are to inform all resources of the name of the assigned incident commander and all other pertinent information. All changes in incident command leadership will be announced to assigned and incoming resources during initial and extended attack incidents.”
In spite of the numerous changes of incident leadership, we found that supervisors and fireline decision makers knew who was in charge and what suppression strategies were to be employed. There was some confusion during the transitions between initial and extended attack Incident Commanders and the incoming Incident Management Teams, but sufficient coordination and communication occurred to maintain consistency in approach and coordination of actions.
Extended attack Incident Commanders had excellent situational awareness and maintained contact with and monitored the performance of the strike teams in the field through both face-to-face and radio communication.
Incident Commanders were focused on assuring appropriate leadership to incoming resources. They formed resources into strike teams or functional groups under capable, local leadership. There was expressed confidence in and the expectation of fireline leadership to relay important, relevant information to assigned resources, and there was ample evidence of effective coordination and mutual concurrence on tactical decisions.
There were differing opinions regarding the policy requiring identification of the Incident Commander. Several individuals indicated their understanding of the policy was that the Incident Commander had to be identified by name, rather than simply to be identified as on-scene and operating using their resource identifier. Others indicated that they believed the Incident Commander was personally required to ensure this policy was met.
· Recommend change in policy where it currently says “name” of the Incident Commander to “identity” of the Incident Commander.
· Recommend that a letter clarifying the policy be provided to the units prior to fire season 2005.
·
Incorporate lessons learned from this fire siege
into future training for all levels of the Incident Commander position as
illustrative of the special needs posed by events such that occurred in
Policy – Interim Directive 5120-2003-2; 5124.04 – “Forest Supervisors also have the responsibility to …distribute Fire Danger Pocket Cards to each fireline supervisor on Type 3,4 and 5 wildfires…”
The pocket cards and
guides were not issued to all fireline supervisors, because they responded
directly to their assignments on the fireline. The conditions presented at the time of the
fire exceeded the levels on the pocket card for both BI (Burning Index) and ERC
(Energy Release Component), and established period of record maximums. The severity of the conditions was well known
to those battling the fire (Strategic
Decision and Assessment Oversight Review – Southern California Geographic Area
Report, 2004).
Incident Commanders believed this responsibility was re-delegated to
them to ensure compliance. Incident management
personnel judged compliance with the letter of the policy impracticable, and
attempts to do so would have been in direct conflict with higher incident
priorities. Instead, Incident Commanders
asserted they provided necessary information to the people who needed to know through
face-to-face and radio contact.
The intent of the pocket
card was met through consistent attention to the maintenance and communication
of information regarding fuels, weather, and predicted fire behavior among fire
suppression personnel. Local resources
were, by virtue of their experience and qualifications, inherently aware of volatile
fuels and predicted fire behavior that is otherwise displayed on the Pocket
Card. Incoming resources were provided
relevant information through on-scene briefings by local chief officers and
other fireline supervisors.
Remove the requirement that Forest Supervisors provide Pocket Cards to each fireline supervisor on Type 3, 4, and 5 fires. The Pocket Card should be presented and utilized as one of several tools that can be used to improve situational awareness regarding current and potential fire behavior.
Policy – Interim
Directive 5120-2003-2; 5124.45 (2) – “Incident Commanders have the authority
and responsibility to assign personnel to fireline positions for which they are
fully qualified, as certified by their employing agency.”
Qualifications could
not be monitored because personnel reported directly to the fireline, were
often out of communication due to radio communication problems, and did not
report to ICP (Incident Command Post) on some fires for up to 3-4 days. Some fireline promotions occurred due to necessity,
but without validation (Strategic
Decision and Assessment Oversight Review – Southern California Geographic Area
Report, 2004).
The Type 3 extended attack organizations were managing rapidly escalating incidents of Type 1 complexity during a critical time period. Incident management personnel judged the compliance with the letter of this policy to be impractical under prevailing conditions, and attempting to do so would have been a significant distraction from higher incident priorities.
Highly qualified local chief officers and other fire management personnel supervised resources assigned from outside the local area. These individuals deployed resources in accordance with their observed capabilities. Arriving resources expressing concern about their assigned task or those being observed as insufficiently prepared for the task were provided more oversight or assigned to areas and tasks that were appropriate for their capabilities, e.g. municipal engines arriving from outside the local area to support wildland operations were grouped with local wildland firefighter resources.
Our qualifications and dispatching systems are expected to provide personnel and resources with the appropriate skills to accomplish the task. There was more reliance on on-scene leadership to perform further assessment and mitigate observed issues.
Strict compliance with this policy may reasonably be expected of Type 1 and Type 2 Incident Management Teams and on many smaller incidents. That expectation becomes unreasonable, however, when applied to Type 3 Incident Commanders in such extraordinary, rapidly emerging events as those under this review.
· Endorse certification and qualification efforts like California Incident Command Certification System, and the adoption or development of such systems throughout the nation.
· Assign resources appropriately by developing strategies and tactics and conducting operations in recognition of the capabilities and limitations of available individuals and resources. Expand the organizations and the work undertaken as additional and more qualified overhead become available.
· Reinforce to those individuals making resource assignments the importance of attempting to validate qualifications of the positions being filled, and that they monitor performance and modify assignments when warranted.
Policy – Interim Directive 5120-2003-2; 5124.45 (6) – “Incident Commanders have the authority and responsibility to personally conduct inspections for safety and health hazards, including compliance with the Standard Firefighting Orders and mitigation of the Eighteen Watch Out Situations on Type 3, 4, and 5 fires...”
Current policy requires the Incident Commander
to personally perform safety inspections on Type 3, 4, and 5 fires.
This expectation is impractical to implement as
written on a rapidly escalating incident, though the intent is sound. While the Incident Commander is responsible
to ensure that safe operating practices are consistently applied, the intent of
the policy can be met by delegation to fireline supervisors by the Incident
Commander. Substantiation of this can be
made with periodic monitoring by the Incident Commander as time allows and as
issues may demand.
Remove the requirement that the Incident Commander
personally provide these inspections (FSM 5130.45). Revise the policy to clearly reflect the intent
that fireline operations be conducted in compliance with safe operating
practices and that monitoring occurs.
Policy – Interim Directive 5120-2003-2; 5124.45 (3) – “Incident Commanders have the authority and responsibility to ensure that performance ratings are completed on Type 3, 4, and 5 wildfires for all ground fireline personnel assigned from outside the local area. Ratings shall include compliance with the Standard Firefighting Orders and the Eighteen Watch Out Situations. Performance ratings shall be maintained in the official incident file and distributed to the individuals rated and their home units.”
It is particularly difficult to ensure
compliance on Type 3 incidents that are transitioning into higher complexity when
local government fire suppression resources are supporting the suppression
effort but not necessarily attached to the incident management structure.
This requirement is impractical on emerging
incidents or during situations involving multiple ignitions. Dynamic changes in resources, such as rapid
build-up or build-down required for resource mobility, combine to make
accomplishing this task difficult at best.
Remove the requirement that these ratings be
performed for every off-unit resource (FSM 5130.45). Emphasize the intent of the policy to provide
ratings in recognition of superior or inferior performance of all resources
involved in the incident and, also, for trainees in all cases.
Policy – Interagency
Standards for Fire and Fire Aviation Operations 2003 (Red Book); sec 5-3 – “Annual
Fireline Safety Refresher Training is required for all personnel participating
in fire suppression or prescribed fire activities who may be subject to
assignments on the fireline...Annual Fireline Safety Refresher Training must
include the following core topics: Entrapments…Fire Shelter.”
Entrapment and
shelter deployment training is an agency specific requirement. Most units responded directly to the fireline.
This requirement could not be validated (Strategic Decision and Assessment
Oversight Review – Southern California Geographic Area Report, 2004).
This was not mentioned during the majority of
interviews. However, a number of
inferences to the inordinate level of tactical responsibility placed on the
Incident Commander could logically be construed as including this issue though
it was not explicitly mentioned. There
was a sense by the Incident Commanders that they had a positive responsibility
to ensure that this training had been received by all fireline personnel.
We confirmed that rapidly escalating conditions
and the concurrent involvement of multiple jurisdictions in initial and
extended attack do not allow real-time execution of this requirement. To explicitly comply with this requirement is
very challenging because non-federal resources are constantly moving between
jurisdictions. There is not a specific
requirement for Incident Commanders to perform this task.
Have the National Wildfire Coordinating Group
(and CWCG in California) work with appropriate agencies or groups to require their
annual refresher to include entrapment avoidance and deployment survival
training for all non-federal personnel subject to wildfire assignments. This assurance will relieve the Incident Commanders
of the assumed responsibility of ensuring the refresher training was completed
by all fireline personnel.
This review was prompted by concern that
our firefighters, in responding to the
Managers were unable to comply exactly
with all safety protocols as written.
For example, they managed fatigue as best they could while attempting to
meet agency requirements, public expectations, and their own sense of
obligation to protect life, property, and resources. Several other safety protocols were similarly
managed, with a focus on complying with the intent of the policy rather than
complying with the letter of the policy.
Managers were apprehensive that post-fire assessments would criticize
their decisions to adjust, adapt or hold in abeyance certain policies that, had
then been followed to the letter of the policy, would have jeopardized the
protection of lives and communities.
We recognize that anxiety over
conflicting demands to comply with safety protocols have prompted several
Incident Commanders to reexamine their willingness to serve in the position and
appear to have deterred additional individuals from becoming Incident
Commanders.
We will never know the full effects of
those who acted so admirably during the fire siege: the lives saved the number of houses not
consumed by the flames, and the sum of grief and loss prevented. However, they are undeniably
considerable. In conclusion, we found
that our firefighters conducted themselves remarkably well and with a high
degree of professionalism. That
professionalism warrants recognition, commendation and perpetuation.
Name Permanent
Position Incident Involvement
Randy Clauson BDF
Division Chief Initial Attack Incident
Commander, Hwy 18
burnout
Bill Bagnell CFFD,
Chief Structure protection
George Corley San
Bernardino County Structure protection, Hwy 18
Battalion
Chief burnout
Rene McCormick BDF
Engine Captain Initial Attack Incident
Commander,
Playground
Tony Osa SHF
Division Chief Incident Management Team
Branch Director
Larry Craggs PNF Battalion Chief Incident
Management Team
Branch
Director for Structures
Jamie Tarne KNF Division Chief Incident
Management Team –
Operations
Section Chief
Mike Dietrich BDF Chief BDF Chief
Rich Hawkins CNF
Chief Initial Attack Incident
Commander
Mick McCormick BDF
Division Chief Initial Attack Incident
Commander
Commander
Hal Mortier CNF Division Chief (retired) Incident Management Team
Incident Commander
Rocky Opliger BDF Deputy Chief BDF Deputy Chief
Tom Brand CNF
Battalion Chief Initial Attack Operations
Section Chief
Norm Walker BDF Division Chief Incident
Management Team
Incident Commander
Gene Zimmerman
Grace Terrazas CNF District Ranger, CNF District Ranger,
Palomar
District Palomar
District
Division Chief = District or Unit
Fire Management Officer or
Battalion Chief = Assistant
District or Unit Fire Management Officer
· Who communicated them?
· How were they provided?
· How did you communicate them?
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Thank you for
agreeing to take this assignment to review the actions that occurred during the
Southern California Siege of 2003 as they relate to our firefighter safety
protocols. You are likely already
familiar with the situation in Southern California, one of the worst fire
situations in
Given the magnitude of the situation and the potential for much greater losses, the wildland firefighter community clearly displayed expertise, excellence, and feats bordering on heroics to contain and control these mega fires. However, there have been widespread allegations that our basic safety doctrines were violated. As such, I am requesting the team conduct this review on the decision space and resulting effects of safety protocols on the firefighter and management of the incidents. This includes:
· LCES
· Work Rest Guidelines
· 10 Standard Firefighting Orders
· 18 Watch Out Situations
· Thirtymile Hazard Abatement Plan
· Interagency Driving Regulations
· IHOG
This delegation of authority requests that you conduct this review, make recommendations for possible improvements in applying safety guidelines in aggregate conflagration situations, highlight opportunities for decision makers to maintain policy guidelines in conflagrations, and provide this information and your findings in a written report.
I would like to have this report completed by
Please refer to the
attached charter for the Safety Protocol Review for a more detailed description
of the team’s objective, background information, the intended scope of the
review, a list of team members, the review itinerary, and a preliminary list of
interviewees.
If you have any questions, please contact Ray Quintanar, the Director of Fire, Fuels, and Aviation at (707) 562-8927.
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Enclosure: Safety Protocol Review Charter
cc: Ray Quintanar, Peter Tolosano, Kent Connaughton, Ed Hollenshead, John Wendt, Larry Hood, Jerry McGowan, Gary Thompson, George C Motschall, matt_kingsley, Gene Zimmerman, Judie Tartaglia
Safety Protocol Review
Charter
Objective
1. Establish a team to review the actions that occurred during the Southern California Siege of 2003 in relation to the following safety guidelines:
· LCES
· Work Rest Guidelines
· 10 Standard Firefighting Orders
· 18 Watch Out Situations
· Thirtymile Hazard Abatement Plan
· Interagency Driving Regulations
· IHOG
2. Make recommendations for possible improvements to the application of safety guidelines in these types of incidents.
3. Review safety policy to determine ways to improve actions during future incidents and improve overall firefighter safety.
4. Highlight opportunities to assist Line Officers and Incident Commanders in maintaining policy guidelines in these conflagration situations (Mega Fires).
Three areas of the 2003 Siege to use as reference for this review will be:
· The Highway 18 burnout operation
·
Defense of
· The Cedar Incident initial attack
Background
During the fall of 2003 under the influence of a mild
From the onset it was obvious to fire managers that these incidents could not be managed successfully in the traditional manner in which other singular incidents have been managed. Due to the speed and intensity of fire escalation, resources were stretched to the limits.
Scope of Review
For this review, the team will examine 2003 Siege fire suppression activities in relation to core safety guidelines in three reference areas:
· The Highway 18 burnout operation
·
Defense of
· The Cedar Incident initial attack
Incident managers have stated that in some cases the requirements of Thirtymile created an undue workload and distraction for fire managers. Several have stated that it was nearly impossible to follow all Thirtymile requirements given the magnitude of the situation. Firefighters were stretched to the limits in attempting to follow policy and became creative in executing planned strategies and tactics.
Questions the review team will consider include:
A review of the focus areas and an examination of the fire management activities in this type of incident will jumpstart the opportunity to research and establish procedures which will allow incident managers to follow existing policy while providing them with the tools to strengthen the decision-making process when faced with this type of incident in the future.
A written report will be generated by the review team and presented to the National Leadership team to illustrate the findings and recommendations.
Team Composition:
Team Leader Kent Connaughton
National Operations Safety Ed Hollenshead
Incident Commander John Wendt
FBAN Larry Hood
Aviation Safety Matt Kingsley
Safety First Chair Jerry McGowan
Writer/Editor Gary Thompson
Research TBA (Possibly David Weise)
Logistical Support George Motschall
Reg. Fire Safety Officer Peter Tolosano
Itinerary:
Week of
Monday-(4/26)-----Travel to
Tuesday-(4/27)-----Conduct Interviews
Wednesday-(4/28)-Continue interviews and start draft report
Thursday-(4/29)----Continue interviews and draft report
Friday-(4/30)--------Out briefing and Closeout by 1300
Report will be forwarded to Kent Connaughton by
Lodging:
To be determined and arranged by George Motschall
Preliminary List of Interviewees
Jim Ahearn Acting Division Chief ICT3, OSC2
Randy Clauson BC 13 ICT3, OSC2
Dan Felix BC 54 ICT3, OSC2(t), FBAN
Bill Bagnell Chief, CFFD DIVS, ICT3
George
Rene McCormick BC11 Acting ICT3, DIVS, OSC2(t)
Tony Osa SHF Team OPBD
Larry Craggs PNF Team OPBD
Jamie Tarne KNF Team OSC1
Mike Dietrich BDF ICT2
Rich Hawkins CNF ICT2
