Thursday, January 8, 2009
From reviews to rollups in incident reports
The after-action review process has been successfully institutionalized in many military and private-sector organizations. The interagency wildland fire community also has adopted the review as doctrine and conducts them as standard operating procedure for capturing and disseminating critical organizational knowledge. Like many other organizations, the wildland fire community continually experiences learning that remains isolated, short-lived and trapped in the memories of individuals or separate units. The review begins a process that consolidates, distills and disseminates knowledge throughout the entire community of practice through the Lessons Learned Center. At both organizational and individual levels, these reviews will help hone wildland fire skills, knowledge and abilities.
The Wildland Fire Lessons Learned Center is in the process of renaming the after-incident report to an after-action review rollup as part of providing you with this valuable tool. The four-question after-incident report, which came from the Army, is one way to elevate the knowledge captured at individual unit reviews for organizational learning. The questions in the after-incident report are intended as a way to summarize the daily after-action reviews. The format for the daily review is found on page 19, or on page 16 of the Incident Response Pocket Guide.
Many operations personnel are beginning to use the daily review, especially after receiving Fireline Leadership training. The daily review also can serve as a useful tool for all incident functions. These daily reviews are designed to provide an internal learning opportunity for the individual unit. Many of you on larger incidents incorporate your lessons and practices from all your functional units into your report, and this is extremely useful information. The intent of the rollup is to provide a formal method for providing that feedback to the entire organization.
The Lessons Learned Center recently facilitated a rollup with one of the Southwest teams using the four-question process. The rollup works well as part of a closeout on any type incident. To view the rollup on line go to www.wildfirelessons.net/AftrIncdntRpt.htm.
Please submit your rollups for all 2003 Type 1 through Type 5 incidents, wildland fire use and prescribed burns.
To further disseminate wildfire lessons learned, Emergency Management Specialists consultant Bob Alvord and Guidance Group consultant Mike DeGrosky recently interviewed engine bosses, captains and crew members regarding their successes, challenges, training recommendations and unresolved issues from recent fire seasons.
USEFUL TOOL FOR ENGINE CREWS
The National Wildfire Coordinating Group publishes the Incident Response Pocket Guide, a field guide containing numerous references and job aids to assist wildland firefighters. On one Northwest forest, all crews on a district use the IRPG as part of their daily work routine and find that it contributes to their performance. The district foremen report that they find the entire guide practical and helpful because it contains many useful references. For example, the district crews use the Size-Up Report on every dispatch. The Size-Up Report is on the inside cover where it is readily accessible and contains all the information initial-attack incident commanders need to gather and report once they arrive on the fire scene. The template in the IRPG prompts the user to collect complete size-up information including the incident name, incident commander, incident type, status, location, jurisdiction, size, fuel type, weather conditions, terrain, access, hazards and concerns, as well as resource needs.
The district's crews also conduct tailgate after-action reviews following each incident. The review is a post-shift crew debriefing method that helps crews learn from the day's actions and events. By consistently using the review process on every dispatch, the district reinforces that the process is not punitive, but a way to identify and make meaningful improvements to their operation. The supervisors emphasize that the review should concentrate on what went right in addition to what should be improved.
Another district uses the note pages at the back of the IRPG to list and define the terms and acronyms that they commonly use. Some engine foremen suggest common fire terms such as those associated with fire weather be included in the next update to the IRPG.
To view or download the IRPG, visit www.nwcg.gov/pms/pubs/pubs.htm.
IMPROVEMENTS TO RADIO COMMUNICATIONS
Inadequate communication often is cited as a root cause of operational problems in wildland fire and other emergency functions. Like all firefighting units, engine personnel depend on reliable radio communications. On one forest, engine personnel noted that their forest's electronics technician has been very effective at improving radio communications, not only on their district, but also across the entire forest. Most of the improvements have resulted from attention to small details that have added up into significant, overall improvement in the communications system.
When the technician came to the forest in 2001, a scheduled radio equipment update had been initiated. However, due to the lack of qualified staffing, much of the old system had not been removed, and nearly all of the antennas and feedlines in use on the system were of 1970s vintage. The technician and his assistant methodically replaced old antennae and feedlines at every radio site on the forest. The last old antenna and feedline were replaced in July. Today, not a single antenna over two years old exists on any hilltop on this forest. The forest's communication system received many enhancements, resulting in significant performance improvements, but the antenna and feedline replacement effort made the single largest advance in system performance.
This forest crew further improved the functioning of its radio communications system when it built two new radio sites to improve system coverage, and when they made the decision to use UHF links only where necessary to replace unreliable telephone control circuits. The forest crew also replaced previous temporary installations with permanent equipment, and new radio buildings were constructed at two district offices to properly house equipment. Additionally, the forest crew replaced all of the antennas at a site that acts as one district's control point for its repeaters. Further enhancing performance, radio towers were replaced as needed, and new ones built at several sites. All communications sites were inspected to ensure they were as clean and modern as practical.
Another successful aspect of this forest's radio communications program is that the electronics technician occasionally monitors forest radio traffic so he can help field personnel improve their radio communications techniques and procedures. The technician's monitoring also enables him to identify potential system problems before they become operationally critical.
The forest's electronics technician makes the following suggestions regarding the use of handheld radios:
- Users can improve their transmissions by holding the handheld radio in a vertical position, three to four inches from the user's face.
- The microphones are designed to cancel noise from side sources, and reduce surrounding background noise. For best performance, anyone using a chest pack should use an external microphone to reduce the background noise level of their transmissions.
- Handheld radio performance also decreases dramatically when the antenna, including the longer G-wave antenna, is held too close to the body or in a position other than vertical. If a chest pack is used in an area of marginal coverage, it may be necessary to remove the radio from the pack to improve performance.
ENGINE ACCESS TO WILDFIRES
The ability of Oregon Department of Forestry to get close to fires with their four-wheel drive, 500-gallon Type 6 engines has resulted in easier containment and control and a reduction in acres burned. The department policy on arrival at an incident is to locate the nearest water source and attack the fire from as close in as is deemed safe. The department preference is to avoid the use of tractors or dozers for access, because of their concern about resource damage to private landowners' property and the potential delay of initial attack if the machinery is not readily available.
REDUCED MECHANICAL PROBLEMS
One district reports that they have experienced very few mechanical problems with their Type 6 engines during the past few seasons because they complete daily safety and maintenance inspections, supplemented by the services of an on-site mechanic when needed. Each day the crews inspect the pump system, the fire equipment and the vehicle. They also go through a pre-trip checklist to check out tires, horn, lights and more, as well as to ensure the required support items are in place, such as a fire extinguisher and first aid kit. The daily safety and maintenance inspection concludes with a road test to check brakes, steering and engine operation.
To view a sample engine inspection checklist, click on www.wildfirelessons.net/Library/Safety_Health/Engine_Inspection_Checklist.pdf.
The Learning Curve
The Learning Curve is a collection of recent lessons learned and best practices from the field, collected and summarized from after-incident reports and from the Scratchline quarterly newsletter by the Wildland Fire Lessons Learned Center, an interagency program supported by the Federal Fire and Aviation Leadership Council. The center works in cooperation with the Federal Fire and Aviation Safety Team, the National Wildfire Coordinating Group's Safety and Health Working Team and Training Working Team, and the National Association of State Foresters. Visit the center or subscribe to Scratchline at www.wildfirelessons.net.
After-action review
The questions in the after-incident report are intended as a way to summarize the daily after-action reviews. The format for the daily review is:
What was planned? Review the primary objectives and expected action plan.
What actually happened? Review the day's actions:
- Identify and discuss effective and noneffective performance.
- Identify barriers that were encountered and how they were handled.
- Discuss all actions that were not standard operating procedure, or those that presented safety problems.
- Why did it happen? Discuss the reasons for ineffective or unsafe performance. Concentrate on what — not who — is right.
- What can we do next time? Determine lessons learned and how to apply them in the future.
— NWCG Incident Response Pocket Guide
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