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Keeping abreast of the reports, articles, and comments generated by the Cramer fatality incident gives rise to many worrisome thoughts.

The accountability issue for fire managers has become a much more important consideration for them than in the past. How did we get to the point that an Incident Commander and the others in the organization are vulnerable to criminal prosecution for errors in judgment?

The shift in managements thinking from what was the norm up until the Cramer incident is far reaching. Some folks thought it short sighted to blame the South Canyon deaths on the burn victims. They were the ones who suffered when the 10’s and 18’s were compromised. The Incident Commander and local management personnel were not held accountable.

Now there has been a change in the level of accountability.
Didn’t anyone think of the implications of changing the accountability level? Shouldn’t the implications of change be thought out before the change is made?

We used to be responsible for our own safety and held accountable for determining what was safe and what was not a safe tactic. That was the way it was for many years.

A major change came about when the agencies handed the OSHA group the 10’s and 18’s as the rulebook of fighting fires. The implications of that were felt by the agencies when fines were levied and the agency held accountable for the violations. The agencies were instructed to correct the violations and make the work environment a safe place to work. The agencies satisfied OSHA with quick fixes but the accidents will in all likelihood, continue to occur. The Tuolumne fire is the next fatality fire following the Cramer fire. How extensive will the accountability be felt?

OSHA may realize that the government is fielding a fire fighting organization that is not capable of avoiding accidents. What will be the implications of that situation? Maybe the accountability will extend to the Chief or the Secretary level or maybe there will be an adjustment to limit the liability to lower levels.

Most firefighters are not threatened or hurt by the fire they are assigned to but they are all threatened by the few who are hurt or killed as a result of a less than adequate judgment of the situation.

Judgment is born from experience. Experience comes from involvement in firefighting. The qualification standards do not develop good judgment from academic exposure. To gain experience and develop good firefighting judgment one must risk exposure and learn from their errors. Two or three training assignments in one position will not be good enough now.

All the firefighters and line officers that supervise them are being tasked to assure there are no fatal errors on their fires. Think of the implications.

Is there anybody that thinks that an organization can run a fire operation of a significant size without making some errors?
How many fires will there be between fatality fires? Judging from the accident statistics, it is evident that there are many mistakes made in between accidents that eventually lead to a fatality.

Some of these errors are:
• Some of the 10’s not being enforced.
• Some of the 18”s not being mitigated.
• Inadequate or no briefings given at assignment.
• Personnel assigned that are not good judges of their situation.
• Independent action taken endangering others.

Many things can go wrong and no one gets hurt.
The way to reduce fatalities is to eliminate unsafe acts. It is unusual to hear of a non-fatality fire having a review with methods designed to eliminate those everyday unsafe acts. Isn’t that the way we were taught to limit accidents?

The reality is that given enough exposure and experience there is a high likelihood that firefighters will become involved in a fatality fire and be subject to criminal and civil prosecution if things remain as they are at present.

The implications could be that there will be less folks willing to become involved in fire suppression activities. Maybe the only ones who do will be those who are forced to because of their job description. It may be necessary to write the tasks into the job description of the folks that are not on the initial attack front lines.
More implications will arise each time there is change.

There’s been lots of talk about developing good leadership. So let’s look at the leadership of the agency.

• Is the agency aware of the consequences of giving the 10’s and 18’s to OSHA, as the rules for fighting fires?
• When another fatality fire occurs in the future does management understand there will be stiffer sanctions and additional consequences?
• If they do, then they must be supportive of what is happening. What are management’s projections of the consequences if the accident frequency does not reduce in the next decade? Will the accountability go higher, to R.F. or above? If they have not determined most of the consequences, they are guilty of inadequate planning.

In any case, the agency has painted itself into a tight corner. The firefighting community doesn’t deserve to be blindsided. We deserve leadership that tells us what the plan and implications of the plan are. We as the fire fighting community want to feel we are in the hands of leaders with good judgment.

Sign me
Waiting for the paint to dry.

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