Errors in Fireground Command Decisions

By Barry Bouwsema

The fireground can be a dynamic and high-stress environment for the fireground commander (FGC). Decisions made in a rapidly changing and potentially unstable worksite can lead to faulty decision process and errors in judgment. . The fire service must train and mentor the next generation of FGCs to ensure that everyone goes home at the end of the day.

Decision errors may develop in one of two ways.The FGC may make a situational assessment (SA) error, in which he incorrectly interprets the presenting problem. This leads to an incorrect decision because the FGC is solving the wrong problem.

In the second case, the FGC may make a course of action (CoA) error, in which he establishes an accurate picture of the situation, but chooses an incorrect course of action.

Several factors contributing to these decision making errors, including ambiguity, underestimating risk, goal conflict, and unanticipated consequences.


Ambiguity occurs when situation’s conditions deteriorate gradually and the FGC’s situational assessment does not keep pace, especially if the cues that signal a problem are not clear-cut. If the FGC is relatively inexperienced, he may not recognize that a different CoA is required. For example, it is often said that it is impossible to put a firefighter in reverse, especially if flames are visible, because firefighters are typically in a “go” frame of mind on the fire scene. If the situation is ambiguous, it becomes more difficult to change the CoA from an offensive to a defensive strategy, even though a defensive approach may be called for.

Underestimating risk

On arrival at a fire scene, the FGC will typically assess both immediate and the near future level of risk. If the FGC encountered a similar risk situation in the past and the fire crew succeeded using a particular CoA, the FGC may anticipate that a similar CoA succeed in this instance as well. Given the uncertainty of outcomes, this may be a correct CoA, but not always. In his book “Human Error”, J. Reason (1990) calls this approach to a CoA “frequency gambling.” Past success influences risk-taking behaviors, and baselines become misinterpreted as a situation becomes increasingly familiar. A previous successful solution may not be the appropriate response to the current problem. Command experience will help in determining if a new solution is required.

Goal conflict

Social factors such as peer pressure may encourage risky behavior. If these social goals outweigh safety goals in an ambiguous situation, a decision error may result. The fire service promotes problem solving and action, but allowing fire crews a few more minutes to perform an interior offensive after the “all out” has been declared may have dire consequences.

Unanticipated consequences

As the fire scene degrades, risk and time pressures increase. As fire scene conditions worsen, the FGC’s ability to mentally project into the future and foresee the current CoA’s consequences may diminish. If the FGC is inexperienced, stress can interfere with working mental capacity and begin to limit the evaluation of options. Under stress, the FGC may fall back on familiar responses which may be inappropriate CoA for the current situation.

The chance of error in fireground command decisions can be reduced by improving both SA and CoA. First, expand the FGC’s experience through training–the first step in improving fireground command decisions. Using realistic and real-time fireground command scenarios, inexperienced FGC’s can learn appropriate decision making for use on actual fire scenes. Appropriate training lays the foundation for successful future fireground commanders.

Second, promote and encourage mentoring within the fire service. Develop correct fireground experience by having a seasoned fire officer coach the inexperienced FGC and help him recognize the sequence of events that occurs on a dynamic fire scene.

Third, fireground simulators offer opportunities to teach the incident command to new commanders; FGCs gain experience and confidence without loss of life or property.

Finally, doubling-up chief officers at fire calls can help prevent fireground command decision errors. The second command officer can serve as a sounding board for the incident commander and function as a resource and planning chief.

Errors in decisions are a realistic possibility on the fireground. By taking a proactive approach to the development of new IC, the fire service can help prevent errors in judgment and make the fireground a safer place to work.

Barry Bouwsem, a 21-year veteran of the fire service, is a fire officer and paramedic with the Strathcona County Emergency Services in Alberta, Canada.

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