BDF Engine 57 Support Mission — Lessons Learned

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BDF-E57_Support-Mission-Report-final-31May2007

Executive Summary

The focus of this mission represented a significant shift from an old rules-based cultural norm in which accidents were inevitably seen as evidence of defects in people’s actions and decisions. On past tragedies, this norm resulted in more rules and greater oversight from both within and outside the Forest Service; efforts to honor and grieve for fallen firefighters were overshadowed by investigations that seemed intent on assigning blame. The atmosphere generated fear and mistrust at the field level as well as unhealed wounds for families, employees, and the organization. People involved at every level of the BDF Engine 57 Support Mission stated that they understood the ramifications and shortcomings of previous support efforts and resolved to take a different approach guided by the values and principles of the agency.

The numerous efforts of the Support Mission included supporting five funerals, conducting a memorial with more than 10,000 people in attendance, hosting family visits to the fatality site, assuming fire suppression duties for the BDF, and providing critical incident stress support to Forest Service survivors.

Based on feedback from families, Forest Service employees, and others, the Forest Service was overwhelmingly successful in its mission. Its efforts to chart a new course—essentially a highvisibility,high-stakes experiment—produced the intended effects: due honor to those who died and compassion for survivors rendered in decisive, constructive, and comprehensive actions. Although the IMT used ICS/NIMS to organize the mission, the way that the operation had to be understood and conceptualized and then planned and executed was entirely different from operations normally undertaken by IMTs. The nature of the mission required delegating unusual levels of authority to division and group supervisors, empowering them to act more like branch directors.

The mission involved identifying intent and focus areas for abstract concepts such as honor and compassion. Adapting to such a mission required the careful judgment of over 275 people from 25 different agencies in an exceptionally stressful situation. With few applicable rules in place, people had to rely on their judgment; they had to apply principles and leader’s intent to make effective and timely decisions. In the end, however, people demonstrated good judgment, employed leader’s intent, applied the principles of the Forest Service, and adapted their tools, including ICS, to a significant and consequential mission.

This mission created broad and complex responsibilities for the Information function. The IMT organized the Information function into a branch as an acknowledgement of the complexity of this function for this mission; however, simply creating the branch came short of solving all the problems that evolved and uncovered inherent weaknesses in ICS regarding organization of information officers. As the USFS assumes other new and varied missions, making conceptual adaptations of ICS to non-fire missions will become more common, be they for responding to tragedy, managing all-hazards incidents, or taking on some other as yet unanticipated task. In the Forest Service’s history, tragedies like the BDF Engine 57 burnover occur often enough to warrant a prepared response. The importance of responding to such event decisively and comprehensively justifies a significant and coherent organizational system to support these efforts. The basis for such a system is the set of foundational principles that explicitly acknowledge the inherent dangers of fighting fire. Such principles allow and encourage the Agency to develop protocols for memorializing firefighters who die in the line of duty and to establish mechanisms for providing needed financial and moral support to the families and the survivors.

Beyond meeting immediate altruistic needs, such foundational principles allow for the building of legal frameworks to protect firefighters while simultaneously holding them appropriately accountable for their judgment and decisions without over-reacting and giving way to a zerodefect

mentality, where a mistake is automatically assumed to mean failure. Current ambiguity around liability, employee rights, mandatory OIG investigations required by Public Law 107- 203—many factors overshadowed this effort and the people who responded, creating an undercurrent of anxiety that affected every aspect of their work.

As a lessons learned report, this document’s purpose and focus is to further the learning and thinking about future responses and challenges. To that end, this report is not a definitive accounting of all that happened; instead it attempts to place the events and decisions of those involved with the BDF Engine 57 Support Mission into a context from which others can derive value from the experience. It provides illustrations of principles-based leadership and incident management in a culture that is shifting from being rules-based to one that is principles-based. The report also is an attempt to add transparency and accountability to this effort to better prepare other IMTs, home units, and agency leaders for future responses to multiple-fatality tragedies and other unprecedented assignments.

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