Wildland Fire Lessons Learned Center

Case Studies

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A Case Study is an exploration of a “bounded system” or a case over time through detailed, in-depth data collection involving multiple sources of information rich in context. (Creswell, 1998) A wildland fire subject area makes a particularly effective case study as is seen in the examples below.

Submit your case study document to the Lessons Learned Center Library (after you login as a registered member) and begin to add to the collection.

Sections: High Reliability Organizing Fire Social Science Wildland Fire Incident Case Study Wilderness and Wildland Fire Use Wildland Firefighter Safety Awareness Wildland/Urban Interface Incident Management Fire Behavior Recent Submissions

High Reliability Organizing

HRO Case Study: HRO Implementation on the Shoshone National Forest (535KB pdf posted 03/17/2009) Personnel on the Shoshone National Forest mark 2006 as a bad year, but one that also demonstrated the Forest’s commitment to resilience. On April 10th of that year, the Homestead Park II prescribed burn escaped control under adverse weather conditions, spreading onto private property and burning four cabins.

Case Study: Incident Management Teams as Vehicles of HRO Implementation ( 779 KB pdf posted 11/4/2008)
In November 2007 Jason Greenlee, Fire Management Officer for the Bureau of Indian Affairs Navajo Office, contacted Anne Black, an interdisciplinary scientist working for the U.S. Forest Service, to inquire about her availability to conduct High Reliability Organizing (HRO) related training. In January 2008, five of the Southwest geographical area incident management teams approved the proposed HRO training as an element of their annual spring team meetings, and Black began the planning process by proposing content to the meeting organizers.

High Reliability Organizing Implementation at Sequoia & Kings Canyon National Parks - An HRO Case Study (833 Kb PDF posted 8/11/2008) SEKI created an institutional structure enabling bottom-up empowerment, effectively institutionalizing self-empowerment in their safety program. Park personnel began their efforts by consciously actualizing one HRO principle; preoccupation with failure.

Fire Social Science
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Factors Affecting Interagency Wildland Fire Management and Recommendations for Future Collaborative Endeavors This thesis deals with factors of success in landscape scale collaborations. Two case studies illustrate effective practices and pitfalls.

Proceedings from the Tucson III Fire Social Science Workshop January 2005. Fire managers and social scientists recieved pragmatic insights from each other in fire knowledge transfer, building partnerships, continuing education in decision-making, human dimensions research and much more about the role of social science in fire.

Wildland Fire Incident Case Study
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Point Fire Case Study July 28, 2005 is the 10th anniversary of the 1995 Point Fire. The lessons of the Point Fire are not widely known, especially to volunteer firefighters. (Colorado Firecamp will be mailing the Point Fire Case Study and video (NFES 2663) to all 300 fire departments in Colorado.) This is a significant incident in the recent history of wildland fire and incorporates all aspects of the BLM Engine Operator course into one case study.

Wilderness and Wildland Fire Use
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Wilderness Burning This link loads a 1 MB Flash Paper version of an 8 MB PowerPoint presentation created by Ralph Swain and given at the 2004 R8 Burn Boss Workshop. (Additional information support document) Need Flash Player? Free two minute download at 56 KB/s.

The Boiler and Dry Lake Complex Wildland Fire Use The Gila National Forest's Black Range Ranger District and Wilderness Ranger District gave this presentation at the 2004 R8 Burn Boss Workshop. This is a 7.5 MB Flash Paper version of the larger PowerPoint file and requires the Flash Player to view.

Wildland Firefighter Safety Awareness
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Presentations given at the 2005 Safety Summit are now posted in our library. Dennis Talbert has provided the Lessons Learned Center an excellent summary document. We have inserted hyperlinks into each of the presentation's titles. The poster presentations are also available on the IAWF Proceedings page.

The Wildland Firefighter Safety Awareness Study was completed in 1998 by the TriData Corporation. The Lessons Learned Center came to be a reality as a direct result of this three phase report. Phase 1, Phase 2, and Phase 3 (Exec. Summary, Chapter 1, 2, 3, 4, 5, 6, 7, and Appendix A, B, C) Implementing Cultural Changes For Safety

Wildland/Urban Interface
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S. California, Texas, & Oklahoma Wildfires: Lives Lost, Lessons Learned ( ppt posted 11/24/2008)
This PPT presentation was given at the Backyards and Beyond Conference in November 2008. It highlights the FACES report from Southern California in 2003 and focuses on initial lessons learned from the 2005-2006 Texas and Oklahoma wildfires.

FACES: The Story of the Victims of Southern California’s 2003 Fire Siege

(5.9 MB DOC Posted 090607)

The FACES of the 2003 Fire Siege is a case study of how six critical tasks provide the foundation of a learning organization. In his dogged and determined quest to unearth the answers to so many questions about how these fires claimed so many people’s lives, Bob Mutch’s actions and findings epitomize all six of the Organizational Learning characteristics.

stephan_bridge_road_case_study_1990.pdf
(14MB pdf posted 1/10/2007)
"A rapidly spreading wildfire swept across 5,916 acres of wildland/urban interface area near Grayling, Michigan beginning around 3:50 p.m. on May 8, 1990./ More than 76 homes and 125 other structures, plus 37 vehicles and boats, were destroyed or heavily damaged during the approximately five hours in which the wind pushed the Stephan Bridge Road fire for a distance of more than eight miles."

black_tiger_case_study_1989.pdf
(3MB pdf posted 1/11/2007)
"A human-caused wildland fire starting on July 9, 1989 in a scenic part of the Rocky Mountains near Boulder, Colorado swept through residential areas nestled among the trees. Within the first five to six hours after ignition, 44 homes and other structures were destroyed and many others were damaged. The fire not was not completely extinguished until four days later, after burning almost 2,100 acres."

The Oakland/Berkeley Hills Fire (4MB PDF Posted 5/5/2006)

Closer to Oakland and also similar to the 1991 fire was the wildfire northeast of Berkeley, which began in September 1923. In 10 hours the fire roared through the Oakland and Berkeley Hills. This document details the fire.

The Slaughter Gulch Fire resulted in an engine burnover the investigation team determined could have been prevented. (This is an 8 MB narrated Flash Presentation and requires the Flash Player to be installed on your computer.) Need Flash Player? Free two minute download at 56 KB/s. Investigation Team Report (1 MB PDF posted 091305)

Using HF Appropriations on Non Federal Land Non-Fed WUI Authorization and Wyden Amendment, authorization and instruments presentation given at the 2004 R8 Burn Boss Workshop. This is a 1 MB Flash Paper version of the PowerPoint and requires the Flash Player to view it. (Notes pages)

Parkhill Area Wildland Fire Pre-Plan and Evacuation Plan Overview (26 KB doc posted 7/27/2005) The Parkhill Area is located 20 miles northeast of San Louis Obispo, CA. It is heavily vegetated with chaparral and in a high risk/high fire activity area. 500 residents live in this area. The Parkhill Area Fire Evacuation Plan brochure was sent to all 500 residents in 2004. Parkhill Area Fire Evacuation Plan (337 KB pdf brochure) Parkhill Area Wildland Fire Pre-Plan (587 KB pdf front side of a foldable poster) Parkhill Area Wildland Fire Pre-Plan Map (605 KB pdf back side of a foldable poster) Thanks to Kelley Gouette for sending this WUI case study to the Center!

Old Fire Lessons Learned Report (332 KB PDF posted 080404) 9-1-1 Consulting Group, Inc. (9-1-1CG) was retained by the San Bernardino County Fire Chiefs Association (SBCFCA) to prepare this report on the I-Zone fire which was named the “OLD FIRE” of the Southern California Fire Storm 2003.

Community Preparedness Case Studies (Link posted 072604) A North Central Research Station research team has been conducting case studies in 15 communities across the U.S. looking at (1) what communities are doing to improve preparedness for wildfire, and (2) the social foundation necessary to support those actions. As part of this study they have produced a series of case study summaries, highlighting each community. They have posted 8 case studies, with the remaining 7 coming the spring of 2005.

Incident Management
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Hurricane Isabel: The National Park Service Response (1.8 MB PDF posted 080504) The National Park Service has completed a report on the response of its incident management teams to Hurricane Isabel – one of the most complex incidents that the NPS has yet managed under ICS, involving five national and regional incident management teams and more than 30 parks in three regions. The report includes a narrative on the storm, summaries of park and incident management team responses, and a critique of those responses.

Command Decisions During Catastrophic Urban- Interface Wildfire: A Case Study Of The 1993 Orange County, California, Laguna Fire (682 KB PDF) By Michael S. Rohde, August 2002 The purpose of this study was to examine the challenges and commonalities experienced by the personnel who commanded six catastrophic California wildland-urban interface fires and how future fires of this nature might be commanded and prepared for. The study includes a description of strategies and tactics specific to the Laguna, Old Topanga, Kinneloa, Harmony, Paint, and Tunnel Fires. Related: Command During Catastrophic Interface Widfires (Overview 119 KB PDF) Article by: Michael S. Rohde, Southern California Firestorm 2003: An Information Collection Team (ICT) Report for the Wildland Fire Lessons Learned Center (567 KB PDF)

Fire Behavior
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The 1988 Fires of Yellowstone and Beyond As a Wildland Fire Behavior Case Study ( pdf posted 7/8/2009) By Martin E. Alexander. This report is the first comprehensive case study that focuses on the lessons learned from the fire behavior during the 1988 Yellowstone Fires. This report is based in part on a presentation featured at the ’88 Fires: Yellowstone and Beyond Conference held September 22-27, 2008 in Jackson hole, Wyoming (Alexander 2009). The author is currently an adjunct professor of wildland fire science and management in the Department of Renewable Resources within the Alberta School of Forest Science and Management at the University of Alberta in Edmonton, Alberta, Canada.

The Mack Lake Fire Part 1, Part 2 "In the first 3-1/2 hours, during which the fire advanced 7-1/2 miles, no amount of fire line or road width held or slowed the fire. After the fire had advanced 4 miles, the passage of a dry cold front turned the southeast flank into a head fire. In the first 6 hours, the fire took one life, destroyed 44 homes and buildings, and burned 20,000 acres of forest land."

Fire Management Today: Wildland Fire Behavior Case Studies and Analysis Part 1, FMT Volume 63 Issue 3, Summer 2003, (1.1 MB PDF) Multiple historical case studies and a tribute to Paul Gleason.
Wildland Fire Behavior Case Studies and Analysis: Value, Approaches, and Practical Uses (64 KB PDF) FMT 63-3 Lead Article by M.E. Alexander and D.A. Thomas

Fire Management Today: Wildland Fire Behavior Case Studies and Analysis Part 2, FMT Volume 63 Issue 4, Fall 2003, (1.2 MB PDF) More case histories.
Wildland Fire Behavior Case Studies an Analysis: Other Examples, Methods, Reporting Standards and Some Practical Advice (83 KB PDF) FMT 63-4 Lead Article by M.E. Alexander and D.A. Thomas

Mann Gultch, Cramer, South Canyon

Below are some other case studies recently submitted to the Center: Back to Top

2WildernessRidgeCaseStudy.pdf
(3MB pdf posted 12/22/2009)
The purpose of this publication is to examine the destruction that occurred on Feb. 28, 2009, in Bastrop County, Texas, during the Wilderness Ridge Fire. The Fire destroyed 26 homes, 20 businesses and 1,491 acres of endangered species habitat.

Historic_2007_GA_Wildfires.pdf
( pdf posted 11/5/2009)
Georgia experienced an unprecedented series of wildfires in 2007. The Georgia Forestry Commission led the effort to control the largest wildfires in Georgia's history which burned for more than two months and destroyed $65 Million in timber.

GA_2007_Wildfires_HRO_ICT.pdf
(724KB pdf posted 11/5/2009)
Today across the wildland fire arena we are discovering the benefits of “High Reliability Organizing”—HRO. We are learning to use this “HRO mindset” as an effective wildland firefighting “tool”. A tool specifically designed to help keep operational errors small. Wildland fire managers and firefighters are also seeing how the five HRO principles can sharpen their decision-making skills—especially during wildland fire’s high-tempo times. They are learning how HRO can help improve their overall skills to better anticipate and contain unexpected events within the wildland fire workplace. This Information Collection Team report explores the lessons learned and effective practices surrounding HRO implementation by the Georgia Forestry Commission and its interagency partners.

Alexander_Yellowstone88_FB.pdf
( pdf posted 7/8/2009)
This report is the first comprehensive case study that focuses on the lessons learned from the fire behavior during the 1988 Yellowstone Fires. This report is based in part on a presentation featured at the ’88 Fires: Yellowstone and Beyond Conference held September 22-27, 2008 in Jackson hole, Wyoming (Alexander 2009). The author is currently an adjunct professor of wildland fire science and management in the Department of Renewable Resources within the Alberta School of Forest Science and Management at the University of Alberta in Edmonton, Alberta, Canada.

Shoshone_NF_HRO_Case_Study.pdf
( pdf posted 3/17/2009)
"Personnel on the Shoshone National Forest mark 2006 as a bad year, but one that also demonstrated the Forest’s commitment to resilience. On April 10th of that year, the Homestead Park II prescribed burn escaped control under adverse weather conditions, spreading onto private property and burning four cabins. On July 18, the Little Venus Fire blew up, entrapping personnel assigned to the fire as part of a fire use module as they hiked into a fire camp, forcing ten firefighters to deploy their fire shelters. As one might imagine, a considerable amount of review, investigation, and soul searching consumed the time and attention of Shoshone personnel afterward."

WHY_Were_They_Entrapped.wmv
(58MB wmv posted 8/13/2008)
This 12 minute video explains much of what happened to the engine crews entrapped on the Madison Arm Fire. Its "A Story of Survival Inside the Transition From Initial to Extended Attack" from the “Firefighter: Remember This” Series created in 2008 by the Wildland Fire Lessons Learned Center.

SEKI_Fire_Management_Operations_Committee_Charter_2008.doc
(47KB doc posted 8/11/2008)
Sequoia & Kings Canyon National Park has created a Fire & Aviation Safety Committee that is truly successful in implementing principles of High Reliability Organizing. This is their charter left in an editable Word doc for you to adapt to your own unit.

Devils_Den_256K_Stream.wmv
(20MB wmv posted 5/1/2008)
This short video briefly and succinctly tells the story of the 2006 Devil’s Den Incident fatality experience — focusing on the key lessons and effective practices to be learned from this fireline tragedy.

Devils_Den_VP6_stream_medium.flv
(30MB flv posted 5/1/2008)
This video briefly and succinctly tells the story of the 2006 Devil’s Den Incident fatality experience — focusing on the key lessons and effective practices to be learned from this fireline tragedy. Streaming .flv Flash Video file for a High Speed Connection (1Mb/s)Requires the Flash Player to be installed on your computer.

Deep_Smarts_Final_052107.doc
(132 KB doc posted 5/15/2007)
"The Fire Management Deep Smarts Project was initiated to capture the experience of our seasoned employees who are acknowledged by their peers to have high expertise in planning and implementing fire programs."

Disclaimer: Information is provided with the intent to share knowledge to improve safety, performance, efficiency and organizational learning throughout the entire wildland fire community. However, no warranties or guarantees are implied because much of the data provided is beyond the control of the Center. No endorsement of any company or product is given or implied.