SOMETHING THAT IS IMPLIED AS A NATURAL CONSEQUENCE
OF SOMETHING ELSE.
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
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
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.
Waiting for the paint to dry.