What THEY Said

As our work on the 2017 Annual Incident Review Summary continues, we’ve got some more analysis to share with you.  Read this.  Do the Exercise and give us some feedback.  The final version of the 2017 Annual Incident Review Summary will be out soon!


By Travis Dotson

In 2017, the Wildland Fire Lessons Learned Center gathered information on more than 130 incidents. Most of these incidents have some sort of report. Many of these reports contain lessons from the perspective of those involved. Here are a few of those lessons – straight out of the reports. Click on the links to the reports if you want more context.


Fallers?Screen Shot 2018-01-24 at 6.24.36 AM

“It’s always nice if fallers have an opportunity to assess and fell hazard trees in an area prior to other firefighters coming in. This is not always available or convenient.

When receiving your assignment, do you always ask if fallers have been through the area?

-What specific scenarios will trigger you to not work in an area until a full hazard tree assessment has been done?”

Tree Strikes Parked Engine


Screen Shot 2018-01-24 at 6.56.48 AM

Plan for Slow

“When establishing trigger points, considerations have to be made for the slow operational speed of heavy equipment (2-3 mph), the slow process for loading and transporting heavy equipment, and the length of the escape route.”

“Effective communications and lookouts ensured that personnel escaped prior to being overrun by the fire. However, there was little margin for error.”

Sheep Gap Heavy Equipment Burnover


Use the LessonsScreen Shot 2018-01-25 at 8.20.33 AM

“ ‘Previous FLAs that I found on a quick Google search helped me make my decision to go to the ER. They were a good resource.’ Ricky cites the following document—created for Crew Leaders to carry with them and take to the hospital when presenting someone with a potential case of Rhabdomyolysis—as being especially helpful in his case: Rhabdomyolysis in Wildland Firefighters

IHC PT Rhabdo Case


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Get Gone or Look Up?

“Do you focus on escape and not pause to look back? Or do you take a few steps and pause for a quick glance back to make sure everything is good? You will have to make this decision for yourself. Use this incident as a way to discuss this ‘where to look’ dilemma with fellow sawyers.”

Sawyer Hit by Tree Top


Don’t Trust Your BrainScreen Shot 2018-02-21 at 10.06.09 AM

“When it comes to assessing fatigue, listen to your body and what it is telling you, not your mind. It may be necessary to accept low-quality rest in order to eliminate driving exposure when your body is tired. The lack of sleep adversely affects sound decision making.”

Return from Initial Attack Vehicle Accident


There you have it, just a few lessons from the front.

Remember, these are just words. YOU choose if they become action.

Circle up and do this simple exercise:


Do the exercise.

Exercise!

 Individually:

  • Identify one of these five lessons that is most important to you.
  • Write down two steps you can take to implement/practice your chosen lesson.

Together:

  • Share your top-priority lesson and implementation steps.
  • Discuss what you do with lessons that can’t be implemented until you’re out on the fireline…how can you improve the likelihood of remembering the lesson?

 

 

Sorting the Lumps

As our work on the 2017 Annual Incident Review Summary continues, we’ve got some more analysis to share with you.  Read this.  Do the Exercise and give us some feedback.  The final version of the 2017 Annual Incident Review Summary will be out soon!


By Travis Dotson

Graph showing 2017 wildland fire incidents

There it is – the 2017 season boiled down to a few lines and numbers. These are all of the “outcomes” from reports submitted to the Wildland Fire Lessons Learned Center. (You can see incidents sorted by “Activity” in last week’s post: “Smokeless Danger“) I made up the categories and sorted them all. For this particular boring graph I tried to simplify everything as much as I could, lumping categories so I had fewer categories (like combining Hit by Tree, Hit by Straw, and Hit by Vehicle).

I’m a lumper…you may be a splitter. I’m ok and your ok (so I’ve heard), but I’ll go into a bit of detail for all you splitters out there. Let’s just go right down the list starting from the “top.”

Exertion – This was almost exclusively made up of Rhabdo and Heat Illness reports (28 out of 31) mostly because there is a specific reporting mechanism (Rhabdo/HRI) for those types of reports. This does not change the fact that the incidents did indeed occur, I just think it’s fair to acknowledge the reporting does seem to follow what we focus on. Nonetheless, HRI and Rhabdo will put you or your crewmembers in the hospital. Plan for it.

Fuel Geyser – Another specific reporting form (Fuel Geyser) helped us get more data on the danger of fuel in your face. So while it’s still happening, it’s fantastic to note that we are seeing significantly fewer injuries associated with the geysers. Is this the result of awareness and education actually working? We would like to think so. Either way, keep pointing that cap away from your vitals when you go to open the tank. Better yet – cover it with a rag, because the geyser remains a distinct possibility.

Entrapment – Big year for entrapments. Heavy equipment got caught the most. They get stumped and they move slow. Fire does not get stumped and it can go from slow to fast very fast. Firing Ops is the other time we often get entrapped – playing with fire is just that. One interesting note, in 2018, of the 20 reports that met the NWCG definition for “Entrapment”, only four chose to describe the event as an entrapment. Why do we avoid that term? (Get busy in the comments y’all.)

Vehicle Accident – Pretty standard. Driving is double-digit danger. We had a few rollovers and a chase truck vs power pole. But what stood out this year was the wheels coming off, or almost coming off. Three different instances of loose lug nuts. Go check your wheels right now (and get serious with those morning PM checks!)

Hit by Stuff – Mostly trees and branches from trees, but also straw from a helicopter. Most of the hit by tree instances involved chainsaw ops, but not always. Those trees will fall on you or throw their big branches at you randomly sometimes. Don’t hang out under them if you don’t need to.

Equipment Damage – Now there’s a broad category. This is usually vehicles being burned. This year there were three of those fire-damaged vehicles plus a couple big rigs (dozer transport and a skidgine) that rolled into trees – super close calls in both instances. Also, one engine’s light bar fell off on the way back to the barn. Check your brakes and the screws on your light bar.

Burn Injury – This bucket always shows up, but this year it wasn’t as full as in previous years. We had multiple instances of folks falling into hot ash, as we do every year. A fire-whirl rolled over an engine on a prescribed fire, someone grabbed a pump exhaust pipe in the dark, and one of those many fuel geyser’s did end up with a fuel ignition/burn injury. There was also one instance of a blown hose spewing hot water resulting in serious burns. In terms of burn injury lessons, this is the one you should read: Temple Fire Burn Injury

Medical Emergency – Super broad category, but it loses its umph when you take out the “exertion” events. What’s left is exactly what you would suspect – cardiac events, seizures, and other unpredictable, high stakes scariness. It might even happen while you are in travel status. Get ready.

Screen Shot 2018-02-13 at 10.01.26 AM

Uno Peak Boulder Near Miss

Close Call – I didn’t have enough room to call this the “No s#!t there I was” category – but that’s what it is. When you end up cartwheeling over a dozer blade. When you’re driving down the road and your brakes fail. When a boulder rolls between two trucks. That kind of stuff.  Random exists whether we want it to or not.

Chainsaw Cut – This is a super sneaky category. There were only three chainsaw cuts this year, but the significance cannot be overstated. Someone died from a chainsaw cut.

All the cuts were to swampers. And it’s going to happen again. Go slow. Be careful. Respect the spinning chain.

Other – There is always “Other.” This year it was a fall off a ladder during structure prep, hazmat exposure during mop up, and a PT session turned search and rescue. Don’t hate…you could be next.

Ok, there’s all the dirty details you pesky splitters. Please do something with all of this information, at least do this exercise:


Do the exercise.

Exercise!

  • Get with two other firefighters and write down which category above means the most to you.
  • Talk with each other about why the category matters to you.
  • Take turns describing what kind of incident you are most likely to experience based on the numbers and your brand of exposure.
  • Write down three ways to prepare for your bad day.

 


 

Smokeless Danger

At the beginning of each year we summarize and analyze incident reports from the previous year.  Check out these previous summaries.  This year we will post individual topics here as we complete portions of the analysis.  Take a look, engage with the exercises, and give us some feedback.  The complete 2017 Annual Incident Review Summary will be out soon. 


By Travis Dotson

This is a graph of incidents reported to the Wildland Fire Lessons Learned Center. This particular graph separates the incidents by Activity (what were they doing when the incident occurred).

There are lots of interesting things to talk about in this graph, please show it to someone who cares and have a nice little talk about what it means to you both. Maybe even circle up with a few others and do the exercise at the end.

2017_IncidentsActivityPTvsFire

2017 Incidents by Activity Graph

I’m sure we all have plenty to say about the “top 3.” They consist of:

  • Chainsaw Ops
  • Driving
  • Physical Training

These are all things we do on a regular basis. Just these three activity types account for 58% of the total. That means in 2017, whenever a report was created and sent to us, more than half the time it was related to someone running a saw, driving, or doing PT.

Take note that none of these activities require a fire. For many of us these are activities we do every day. That’s telling. It means things we do a lot are things that bite us in the ass.

What am I getting at? It’s pretty simple. The “danger” isn’t necessarily hiding on the fireline, it’s stitched right into your daily activities.

Are the briefings before PT different than the ones before the big burn show on Division Delta? Of course they are. They are different activities. Plus, none of us could tolerate a big deal briefing every day before PT.

Maybe I should reframe it: which operation is more likely to go bad? That, of course, is a loaded question. You can slice and dice the exposure, frequency, risk, danger, possibility, hazard pie all kinds of crazy. You could make this a spicy dish with whatever flavor your over analysis happens to be. You could also use math, but I think you might need other numbers to do that. I don’t have the numbers or the math mojo to tackle it.

But I do know that I don’t think of PT as dangerous. Turns out I’m wrong. Imagine that.

Get together with the people you PT with and do this simple exercise:


Wheel

Exercise (15 minutes) In small groups discuss the following questions:

Is PT really more dangerous than Firing Ops?

What is the danger of NOT doing PT?

Is your medical plan equally good for both operations (PT and Firing Ops)? – Should it be?

That’s all.

Now go PT.


 

Fatal Attraction

As our work on the 2017 Annual Incident Review Summary continues, we’ve got some more analysis to share with you.  Read this.  Do the Exercise, and give us some feedback.  The final version of the 2017 Annual Incident Review Summary will be out soon!


By Travis Dotson

We love to know how many firefighters died. It’s the only number anyone has ever frantically demanded of the Wildland Fire Lessons Learned Center – all other numbers inspire no urgency.

Why do we want to know? What is this morbid fascination? Is it morbid?

The highly esteemed Urban Dictionary has a definition for the term “Fatal Attraction” –

“An attraction between an individual and someone/something that is so strong, the individual lacks reason and logic in their thinking when dealing with their attraction.”

obsessed-with-work

Does our fascination with firefighter fatalities fit this description? Do we lack reason and logic when dealing with our attraction? The most basic line of thinking goes something like this – if we pay attention to dead firefighters there will be fewer dead firefighters in the future. That feels reasonable, but is it?

Here are the basics from 2017.

2017 Wildland Firefighter Fatalities

Vehicle Accident: 4

Medical Emergency: 3

Hit by Tree: 3

Entrapment: 2

Hit by Straw: 1

Chainsaw Cut: 1

Total: 14

Now what?

How will you use logic and reason when thinking about this topic?

Is this year any different? Here are the numbers from the past ten years:

10yrsFatal

 

 

We can go past ten years as well. The average number of fatalities over the past 30 years is just under 17. In case you are wondering, that’s 500 deaths since 1988.

Now what?

I don’t know – and I’m the analyst at the Wildland Fire Lessons Learned Center.

What if we just thought about how we talk about Line of Duty Death?

Gather up with your fellow risk-takers and do this:


Exercise (30 minutes)Wheel

Part 1 (5 mins)

  • Individually list as many “sayings” as you can about Line of Duty Deaths – for example, “we haven’t found any new ways to kill firefighters” or “all our lessons are written in blood.”

Part 2 (25 mins)

  • Take turns saying one to the larger group. Discuss what these sayings really communicate.
    • Are they true?
    • Are they useful?

 

I have no idea if that exercise includes any logic or reason, but it does get us to examine the words we use and why.

Maybe we should try changing our words – or at least know exactly why we say them.

Mic Drop

As our work on the 2017 Annual Incident Review Summary continues, we’ve got some more analysis to share with you.  Read this.  Do the Exercise, and give us some feedback.  The final version of the 2017 Annual Incident Review Summary will be out soon!


By Travis Dotson

You got a mic? Are you a wrapper?

Ha Ha – lots of people didn’t get that.

Rewind:

  • Do you have an external microphone for your radio? (“mic”)
  • Do you wrap the cord through the webbing on your line pack? (“wrapper”)

See how it’s not funny when I explain it?

What the hell am I even talking about?

Screen Shot 2018-01-12 at 10.54.02 AM

An External Radio Mic

I’m talking about needing to ditch your gear, grab your radio, and run for your life. See, that’s where the mic cord becomes a problem. The problem is when you are trying to escape from a wall of flame bearing down on you it can get hard to do things – especially things that need to be done fast. Fiddling with intricate little parts is a giant pain in the ass – especially with gloves on, and when it’s hot and you know with more intensity than you ever have that the smallest delay is deadly. Literally deadly.

You know where I’m going. It turns out it’s rather difficult to ditch your gear, grab your shelter, radio, and water when your radio mic is woven through the gear you are trying to ditch.

For those of you who are thinking “just don’t weave the cord, let it hang loose” – you might never have tried to actually work, especially in brush, with a loose cord dangling here and there. The environment we operate in is mean. It turns out trees, brush, tools…even rocks, all have deceptively intense grip, strength, reach, and are plain old sneaky as shit. That cord will be grabbed and held when and where you least expect it. This is why we invest so much attention in a tightly woven cord. We are trying to outwit the wrathful reach of that vengeful vegetation.

Yes, the mic cord is intentionally woven tight for good reason. But that good reason gets tangled up with survival in certain situations.

Check it out:

From the 2012 Holloway Entrapment report: “Firefighter A moves into the only opening she can see, removes her pack, gloves, then removes the fire shelter, discards her fuel bottle, and attempts to remove the radio and water from pack. She has difficulty retrieving the radio due to the remote microphone cord being intertwined in the line pack webbing.”

From the 2017 Preacher Fire Entrapment report: “Iron Mountain lookout was trained to drop line gear to lighten his load. He knew he needed to take his radio, fire shelter and hand tool. He threw his line gear on the upper cut bank of the road to remove his equipment. The cord to his external speaker mic was woven into the webbing of his line gear, which is something that many firefighters do to keep the cord out of the way. The urgency of the situation made it even more difficult to disconnect his radio mic. He felt it took an extraordinary amount of time and was extremely frustrated when he finally removed the radio from his line gear.”

 

See the problem? Pretty straightforward. When you are running for your life and go to ditch your gear but want to keep your radio (as you were trained) that external mic can be a real time sink, and you got no time to sink.

So what to do? Figure it out yourself. I’m not trying to be an ass. I just know we are a bunch of inventive bunnies and we put a lot of stock in things we come up with ourselves which means you are likely much better served if you customize a solution that works for you. So go do it.

You just got served (a lesson that is).


Wheel

Exercise (30 minutes)

  • Gather up with a few other folks who carry radios. Discuss the practice of “weaving your mic cord” through pack webbing.
    • What are the pros and cons? (10 mins)
  • Identify 3 ways to avoid the cord problem from the entrapment fires listed above. (10 mins)
  • Decide as a group if there is a reason to make a rule about this type of cord set-up? (Take a vote if you need to.) (10 mins)

Go get your gear if you need to make changes.

Are Some IMTs Making Emergencies Harder to Manage?

By Jayson Coil, Battalion Chief Special Operations and Wildland Fire, Sedona Fire District, Arizona

I have a rule about not setting things on the top of my toolbox when loading-up for an assignment. This rule was developed after a new coffee cup and a BK radio slid off the toolbox and into traffic as I was leaving. So, I conducted my own little AAR as I filled out the damaged equipment report and realized that even though I intended to put them both in the front seat, there were distractions that prevented me from doing so.

On incidents, standardizing helps avoid bad outcomes by creating a shared understanding and expectations. When I think about how we make decisions and apply our training and experience to avoid costly errors, this standardization makes sense.


Do you remember what direction Wagner Dodge gave the rest of the jumpers when he realized the fire was below them?


When faced with a high stress, serious consequence situation, we do not engage in a strict comparison of options. In fact, we typically have incomplete information that requires us to continually reassess and validate the decision as the situation becomes clearer. So, we fall back onto our training and utilize recognition primed decision making (RPDM). And if the slide in our head—even if it’s a slide we developed in training—lines up with the reality we are facing, we make higher-quality decisions.

Do you remember what direction Wagner Dodge gave the rest of the jumpers when he realized the fire was below them? He told them to drop everything heavy. This was not anything they had practiced. Different crew members interpreted the order to mean different things. Because of this and other tragic events, we now incorporate “dropping your tools” into shelter training and conduct exercises on static and dynamic deployment. So at least in that example, we have demonstrated that we recognized developing a standardized approach to a critical task and practicing to proficiency makes sense.

Developing Good Checklists

There’s another reason why I think we should ensure that all IMTs follow a standardized approach. It has a lot to do with airplanes. When United Airlines Flight 173 ran out of fuel over Portland, Oregon and ten people were killed, the National Transportation Safety Board (NTSB) listed the probable cause as: “The failure of the captain to monitor properly the aircraft’s fuel state and to properly respond to the low fuel state and the crewmember’s advisories regarding fuel state. This resulted in fuel exhaustion to all engines. His inattention resulted from preoccupation with a landing gear malfunction and preparations for a possible landing emergency.”

From this event and the subsequent work to reduce human error, crew resource management (CRM) was developed. In fact, CRM was one of the first books included in the wildland fire leadership development program. In CRM they recognize that checklists, such at the medical incident report, are effective ways to develop reliability and consistency. A good checklist establishes common ground, provides for standardization, serves as a cognitive aid, and reduces error.


We did our AARs and serious accident investigations and we took steps to standardize and improve. But, not every IMT has adopted the new standards. I don’t understand why.


So, I have explained why I believe we should train the way we perform in the real world and how the lessons learned in CRM can be applied to real life. If you think about my poor coffee cup and radio, a checklist that ensures nothing is on my truck before I pull out is a good thing. It would be even better to establish a standardized practice of never putting anything onto my toolbox. Also, I bet most of you know someone who has been hunting and leaned a gun against their vehicle only to drive off. That is a little off topic, but another practice to avoid. Trust me.

I Don’t Understand Why

A more serious example is the process improvements we have made for managing medical emergencies on fires. After Dutch Creek, we developed new protocol and the 9 Line. In 2014 we got a new med plan, the ICS-206WF, which included the medical incident report (MIR). We even added the MIR to the IRPG so everyone would have the same script to follow when reporting an emergency.

We did our AARs and serious accident investigations and we took steps to standardize and improve. But, not every IMT has adopted the new standards. I don’t understand why. Some IMTs still use the old ICS206 and some change the reporting requirements so they do not align with the MIR and the IRPG. Is their behavior aligning with the teaching of good CRM or what we should have learned from Dutch Creek? I don’t think so.

When there is high stress, new priorities, incomplete information and difficult environmental conditions, we are not going to take the time and consciously align our behavior with the model that a particular IMT has chosen to adopt. Sorry, but that is not how people behave.

Those people in the field who are managing the emergency will use their intuition, experience and training. If an effective and coordinated response that provides the greatest possibility for a positive outcome is the goal, we all need to align. To put it another way, if one of our top priorities is to increase the likelihood that an emergent event that threatens the life of a firefighter is handled as effectively as possible, then we need to follow the standard on every incident.


If an effective and coordinated response that provides the greatest possibility for a positive outcome is the goal, we all need to align.


The people we place in high-risk environments should know the training they have engaged in to effectively manage an emergency will apply. Sure, it’s more difficult for the MEDL to get all the information and it also takes up a few more pages in the IAP, but I fail to realize how either one of those issues trumps consistency and clear expectations for the crews in the field.

The way I see it, we have lots of things we can change, including: briefing times, the order of briefing, how far the toilets are from the sleeping area, if we are going to let crews spike out, collar brass, no collar brass. The list goes on and on. With all that ability to change stuff, let us all agree to leave the ICS206 WF and MIR standardized. Deal?

Bad Refreshers

By Travis Dotson

old-school-teaching

We have all been there.  The seated refresher.  All day in a chair.  Even if the videos are good, the process gets old.  The set up is not conducive to learning – it’s more likely to result in drowsiness and habitual Facebook scrolling.

So why do we do it?

We all know most folks get told “you need to put on the refresher this year.”  Then that person just replicates what they have sat through in the past.  We are not professional educators so what we get makes sense.  I happen to think there are a few small steps we can take to make our yearly tune up just a bit better.

1. Be Relevant: Use this: Annual Incident Review Summary I know – shameless plug for LLC stuff, but this thing is purposely built for injecting relevancy into curriculum.  It’s what happened last year.  It’s what those in the bulls eye had to say about what happened to them.  It has exercises you can do.  Modify them to suit your situation.

2. Go outside:  There are so many ways to do this.  Do a classroom section on driving and then load everyone up and drive to a field site for the next section.  That is real deal theory/application right there!  You could even design your own Staff Ride that meets refresher requirements!  If weather does not allow, replace outside with stand up and move around.

3. Prepare:  Use this: Wildland Fire Safety Annual Refresher Training  Again, it’s purpose built.

4. Be honest:  Talk about real stuff.  Authenticity matters.

5. Look to experts:  Be inspired by TED talks.  Show one and discuss it, we love relating non fire stuff to fire.   Go further.  Make presentations look like TED talks.  Don’t talk for more than 20 minutes – ever.  If you have a screen, don’t put lots of words on it – use pictures.

That’s all.  Just five things that could help.  Maybe just do one of them.  I’m sure you have ideas of your own – share them in the comments.