Tailboard Talk: Did your Last Emergency Incident Go as Well as it Could Have?

By Craig Nelson and Dane Carley

You are in the middle of another routine day when the tones go off for a fire in an apartment building. You may be the senior firefighter filling-in, a company officer, a battalion chief, an assistant chief, or the chief. Anyone in these roles could quickly find themselves staring down the barrel of the incident commander (IC) position. It may be your first or 1,000th time in this position, but either way, this important role must be filled. The outcome will depend upon your previous experience, education, and training (and your crew’s abilities, because great crews have a way of making their superiors look great). Do you perform well as an IC? Over time, have you gotten better at it? Why is this so important? It is important because the IC plays a vital role in the incident command system (ICS). Have you ever heard “the outcome of an incident is determined in the first few minutes?” We believe there is a lot of truth to this statement, which refers to the initial actions taken, one of which should always be establishing command and using the ICS.

In the fire service, we use the ICS because it is a system that is designed to help us perform better. This is especially important for those of us working in high-risk, high-liability environments (the fire service) because mistakes can be costly. How does ICS help us? It helps us to plan, organize, and prioritize information. It is also designed to help us move the timely and important information up and down the ranks in an organized effort to mitigate an incident–it is primarily designed to be a communication tool instead of a management tool (Bigley & Roberts, 2001). Are you using it correctly? Of course everyone will at first say yes, but stop and think about how well you performed each of the many aspects of the ICS at your last fire. The ICS only works as well as the people using it, and as far as people are concerned we haven’t found a perfect one yet in the fire service, although firefighters are about as close as you can get to perfection. This is where higher reliability organizing comes in; it helps us improve our use of the ICS and it can also be used to improve our performance with all of the other systems currently being used in the fire service. As diligent members of the fire service proactively planning for the future, we can also use higher reliability organizing to help us as we integrate new and emerging systems.

Regardless of how much we may think systems are boring or unimportant, they play a vital role in much of what we do every day in the fire service. Although the many systems we use help firefighters every day, we don’t often realize it. We often just think of them as things we do, but it is difficult to determine how well we are performing with the systems if we don’t recognize them for what they are. We also realize that change and “new” methods are not easy or fun, but again the reality is that the one constant in the world is change, and we can either hide from it (letting it and the rest of the world pass us by), or embrace it to make ourselves better at what we do. This does not mean that we are recommending change for the sake of change. We are saying that we must constantly watch for and evaluate new emerging products, methods, and systems. We can then use higher reliability organizing to help us improve our use of current systems, but it can also help us evaluate and integrate new systems too.

Tailboard Talk: Did your Last Emergency Incident Go as Well as it Could Have?

ICS as an HRO System

People in a higher reliability organization (HRO) are trained to get the most out of the systems they use. For those of us in the fire service, ICS is just one example of a system we could improve our use of. Coincidentally, it is also a system that should be an important part of every fire organization. If your fire service organization is an HRO, then you already actively use its principles and employee behaviors to excel, and not just with the ICS. A closer look shows how HRO traits can be used and maximized in the ICS system. As you look at each of the following HRO principles and behaviors examples, think about how you and your organization approach ICS and whether you are getting the most out of it that you can.

One of the best incident commanders (Chief Balstad) we have ever seen took great pride in his role and spent a lot of time training, practicing, and reviewing his performance (he actually used to pull every 911 audio tape of his fire incidents from dispatch). He was exhibiting HRO principles and behaviors. The result in this case was that his scenes were mitigated in a safe, calm, orderly, and effective fashion. An HRO approach helps us all work toward continual betterment of ourselves and our organizations. Along with the training and practice most of us already put in, it takes understanding where the real weaknesses lie and knowing how to address them. Here are some examples of how your organization can start down the road to continuous improvement by addressing some common ICS areas of improvement:

HRO Principles in Relation to ICS (Weick & Sutcliffe, 2007)

Preoccupation with Failure — seeks out and focuses upon areas where failure is likely to occur or has already occurred. ICS might be likely to fail in areas such as accountability and/or communication.

HRO Solution: A pro-active approach might involve looking at the most common causes of near-misses and accidents and then training on the most common and the most hazardous.

Reluctance to Simplify — practices prevention of complacency and/or reduced situational awareness. ICS may be likely to become complacent by not always being formally established. Many of the worst scenes we have witnessed never had ICS formally established. ICS may also lose situational awareness when overloaded (this can happen very easily if one person is trying to run all of the positions at an incident–think span of control).

HRO Solution: Practice formally establishing ICS at every multi-company incident and training exercise. Use a scribe, assistant, or another officer to you maintain situational awareness at all incidents, but especially those that increase in size or complexity.

Sensitivity to Operations — constantly asks what is happening “on the streets” or “inside the burning structure.” ICS was designed to be a two way system of communication. It is common to see ICS lose sensitivity to operations by becoming a top-to-bottom-only communication tool. If you are the IC, then how well informed are you if you are not using information from the crews inside to make your decisions?

HRO Solution: Seek out and encourage your crews to communicate important information to you! This includes emergency scene information and daily operations. Hint: if all you’re hearing is how great you are, then you aren’t getting real information.

Commitment to Resilience — means you are committed to future success which requires improvising, reacting, and changing as needed. It also means that you seek this out and teach it to your fire department members. This is similar in the sense that, when plan “A” doesn’t work, you go to plan “B,” and so on…This is a strong area for the fire service, but a common problem might be an organization that has become “in-bred” because they never seek outside training or ideas. This results in a “there is only one best way to do things” mentality that crushes creativity and improvisational skills.

HRO Solution: Have crews practice using the ICS on the training ground and let them apply different strategies and tactics to simulated emergencies to build improvisation and resilience skills. This allows them to see the pros and cons of different approaches, learning where one may work better in one situation than another.

Deference to Expertise — simply put means using the person with the most knowledge, training, and ability in a subject to help make decisions, regardless of seniority or rank. If you have an emergency scene involving an electrical hazard an there is an electrician on your crew or department, then use their expertise to help you make decisions at the scene even if they only have one year on your department. A likely ICS situation where deference to expertise may not be used is one where the newest crew member (maybe still even on probation) is the person with the expertise and the rest of the crew/organization believes that they are new and could not possibly have anything valuable to add.

Solution: Get to know each organization/crew member as soon as you get the chance. Ask them about their background, previous work experience, hobbies, and training. This will help you get to know them and their abilities. When a situation arises where their skills could be of use, you will be ready to put them to work.

HRO Employee Behaviors to build and encourage for use in the ICS (Ericksen & Dyer, 2004)

Situational Awareness: Employees who have situational awareness have a good understanding of what is happening. As such they have a better idea of what needs to be done and how to accomplish it.

Communication: Employees who are trained to communicate well know what to say, when to say it, and how to say it. They are also not afraid to say it. For those working in a hierarchal structure (fire service), one of the most common communication problems is a lack of assertiveness in junior members to speak up when they see something important (this is another one of those problems that we don’t think we have, but we do).

Recognize and React: Employees who are trained to recognize and react see what is happening or what may happen and begin to come up with possible solutions, whether it is at an emergency scene or something that may impact department operations.

React and Adapt: Employees with the ability to react and adapt take the possible solutions in the previous example and find the best methods to affect the changes. They also are comfortable and good at change, which for most people is difficult and requires a lot of training and practice (embracing change is a problem we know we have along with almost all other humans, but it is tough to fix).

Engage Others: In this, case employees realize the importance of seeking out the help of others, even outside of the department to accomplish tasks (law enforcement, EMS, public works, utilities, politicians).

Improvise: Improvisation is a strong point for many in the fire service because we are trained heavily in this area for tactical emergency operations, but from an HRO perspective this is also an important skill to train on for daily and strategic department operations

Learn: In an HRO employees who learn practice skills until they become second nature, but they also learn about their own strengths and weaknesses as well as their departments, so they know where to focus their future efforts.

Educate: An employee with the behavior of educate realizes the importance of making themselves better. They also realize that the more methods they use, the better. They will train, attend continuing education, and credit classes that will all work together to broaden their understanding of their profession. These are the people you see at conferences like FDIC.

Case Study

The following case study is from www.firefighternearmiss.com. The near miss report, 13-0000305, is not edited. We were not involved in this incident and do not know the department involved so we make certain assumptions based on our fire service experience to relate the incident to the discussion above.

Event Description

Note: Brackets denote reviewer de-identification.

On [date and time omitted], units responded to a reported residential fire. The fire was reported by neighbors. Initially, there was some confusion regarding the address, which was cleared up quickly.

A staff unit arrived on scene to find heavy smoke and fire showing from the B/C corner of a two-story duplex during the 360. The staff unit advised over the radio that the residence was “all clear” of potential civilian victims. Shortly after the staff unit went on scene, the first-in engine arrived and established a personnel staging area. The first-in engine’s crew began to deploy two 1 ¾” lines for an offensive attack.

A rescue unit arrived and the captain assumed command. A mutual aid engine and mutual aid battalion chief had responded as automatic mutual aid. The mutual aid engine was directed to obtain a water supply by command. Crews from the first-in engine, med unit and rescue began an aggressive interior attack with a backup line manned on Side “A”. The first-in engine’s crew along with personnel from the med unit, and rescue quickly extinguished the fire on Division”1′ and began moving to Division “2” to search for and extinguish the fire on Division “2”.

The first-in battalion chief and others arrived on scene. After a face to face with the battalion chief, the captain was assigned Interior and the battalion chief assumed command. A lieutenant was initially assigned to Safety by the captain when he was incident commander. The mutual aid battalion chief was assigned to Safety by the battalion chief and lieutenant (Safety) was changed to Accountability. Assignments were made for additional lines manned by the mutual aid engine and RIT (Ladder crew). The third-in engine’s crew was assigned to ventilation of the Division “2” windows on Side “A” and the roof. Command elected to deploy the second rescue’s crew into a window near the “B/A” corner of Division “2” to assist interior crews with opening up the ceiling and walls. Additionally, the third-in engine’s crew was advised to flow a hand line into the roof vent at the peak of the roof of Side “A”. The line was also directed into the window of the involved part of the structure. Conditions became untenable where the second rescue’s crew was and the captain gave the order for his crew to exit the structure by way of the ground ladder. At one point this crew was engulfed in fire prior to exiting the structure. One member fell about 15 feet when he was executing a ladder bailout. Command advised all members to exit the structure immediately to initiate defensive operations. After all members had exited the structure a PAR was conducted and confirmed. Defensive operations began and the main body of fire was knocked down. Immediately following the knock down, interior operations commenced and all “hot spots” were extinguished. Salvage and overhaul operations were completed with the residence being turned over to the investigator.

Lessons Learned

We learned that although it does not appear that flowing a handline into a gable vent would have such a detrimental effect on the fire operations; it does and therefore should not be done. Also, we should review our tactics on scene and seek the advice of others if we are not certain that what we are doing is going to assist in extinguishment or put fire personnel in undue danger. It is best to have more than one person at the command post or an operations officer so we are sure that the procedures are being followed.

As firefighters, we must always be aware of conditions we are entering and how rapidly they may or may not be changing.

– Accountability

A Lieutenant was assigned as the Accountability Officer after he was assigned as the Incident Safety Officer.

– Safety Officer

Early assignment of an Incident Safety Officer was done. The mutual aid Battalion Chief was later assigned to this position.

– Communications Model

Radio communications are a must in order for all members to be aware of what is happening on the scene. It is imperative for the receiver to repeat them over the radio to ensure reception.

– Tactical Considerations

Exterior hose streams directed into the structure should not be used while interior operations are taking place.

A master stream should be considered to obtain a quick knock down and facilitate interior operations when a defensive attack is used.

– Preplanning

All stations that have “Mill Houses” in their assigned areas must remember the construction type and hazards associated with them. Many of these have been remodeled but the tongue and grove construction is usually Our covered up by remolding. Also, these residences have large open areas under the hip roof construction on Side “C” which will allow combustion products and fire to travel unimpeded.

– On-Deck Area

Early recognition that additional resources most likely will be needed should be noted and called for prior to the depletion of on scene resources.

– Apparatus positioning

The position of all responding vehicles must be carefully chosen; if all reports of fire are treated the same, the spotting of vehicles will become second nature. Care must be taken when laying 5″ hose to move the hose to the curb prior to charging if at all possible.

– Communications Infrastructure

Some portable radios were not operating properly due to being wet. This is an ongoing problem.

– Evacuation Procedures

Personnel should exit the structure as soon as command determines that a change to defensive operations should commence. Some personnel were hesitant to exit due to concerns that members may be lost in the structure. This is understandable but, we must remain disciplined in order to maintain the highest safety of all personnel on the scene. Correct procedures for these situations are found in our SOP.

– Ladder Placement

Ladder placement for rescue should be at the bottom of the window seal. The ladder had to be adjusted for rescue after it was placed in service on side “B” for crews to enter the structure.

– Progress Reports/ Situational Awareness

All members should maintain a heightened awareness of their situation and the conditions within a structure. If the conditions deteriorate or the structure becomes unstable, command should be updated as soon as possible.

Regular and timely updates of progress or conditions within the structure are required to enable command to make necessary tactical decisions.

Discussion Questions

1) How would you rate your organizations and your own performance with the ICS system? As an IC?

2) What do you do or what does your organization do to improve you performance with the ICS? As an IC?

3) What HRO principles or employee behaviors would be most beneficial to you or your organization to improve performance? Why?

Where We Are Going

Our last article introduced a list of specific systems the fire service currently uses and may use in the future. Each specific system uses some of the HRO principles and employee behaviors to contribute toward success. This month’s article transitions us into an in depth look at how a specific current fire service system incorporates HRO concepts. Next month’s column will continue our discussion of specific fire service systems which use HRO principles and ROEBs to encourage effective performance. We would appreciate any feedback, thoughts, or complaints you have. Please contact us at tailboardtalk@yahoo.com or call into our monthly Tailboard Talk Radio Show on Fire Engineering Blog Talk Radio.


Bigley, G. A., & Roberts, K. H. (2001). The incident command system: High reliability organizing for complex and volatile task environments. Academy of Management Journal , 44, 1281 – 1300.

Ericksen, J., & Dyer, L. (2004, March 1). Toward A Strategic Human Resource Management Model of High Reliability Organization Performance. Retrieved February 18, 2010, from CAHRS Working Paper #04-02: Cornell University, School of Industrial and Labor Relations, Center for Advanced Human Resource Studies: http://digitalcommons.ilr.cornell.edu/cahrswp/9

Weick, K. E., & Sutcliffe, K. M. (2007). Managing the Unexpected: Resilient Performance In an Age of Uncertainty (2nd ed. ed.). San Francisco, CA: Jossey – Bass.

Craig Nelson & Dane Carley: Tailboard Talk

Craig Nelson (left) works for the Fargo (ND) Fire Department and works part-time at Minnesota State Community and Technical College – Moorhead as a fire instructor. He also works seasonally for the Minnesota Department of Natural Resources as a wildland firefighter in Northwest Minnesota. Previously, he was an airline pilot. He has a bachelor’s degree in business administration and a master’s degree in executive fire service leadership.

Dane Carley (right) entered the fire service in 1989 in southern California and is currently a captain for the Fargo (ND) Fire Department. Since then, he has worked in structural, wildland-urban interface, and wildland firefighting in capacities ranging from fire explorer to career captain. He has both a bachelor’s degree in fire and safety engineering technology, and a master’s degree in public safety executive leadership. Dane also serves as both an operations section chief and a planning section chief for North Dakota’s Type III Incident Management Assistance Team, which provides support to local jurisdictions overwhelmed by the magnitude of an incident.

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