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.