All current investigations involving fatalities are mandated to determine the cause of the accident so that corrective actions can be taken. There are presently two types of investigations that result in the following outcomes:
- Land management agencies choose to use the findings to educate their employees to become more aware of the critical factors involved in fatal accidents. The goal is to enable employees to learn from and avoid future similar situations. This is the Learning Culture approach.
- OSHA or state authorized administrators of the federal agency (such as Arizona Division of Occupational Safety and Health) are legally bound to determine if policies, rules and/or regulations were not followed, issue citations based upon their determinations, and mandate changes to rules and/or regulations to avoid future accidents.
The land management approach generally works for non-fatal accidents and near-miss situations, but when a fatality occurs this approach appears inadequate. Most cases with fatalities will result in litigation. The determination of fault for the fatality will be decided on the basis of the investigation and litigation.
Some of the problems that can arise within and from the two separate investigation formats are:
- Investigations with different outcomes result in confusing messages being conveyed to wildland firefighters and the public.
- Conducting separate investigations results in redundancy and unnecessary expense.
- The specified time periods for investigations are sometimes as little as two months and usually not more than six months. Complex investigations are hindered by these time limits. Conclusions that would be more accurate and robust if additional time was allowed are not reached.
We believe that a National Transportation Safety Board (NTSB) model of accident investigation would better meet everyone’s needs in investigating wildland fire fatalities. This approach would allow a single independent investigation of the accident by an impartial group of specialists. The advantage is that this model is not constrained by time, agency agendas or associated politics, or public pressures. When the NTSB completes an investigation the findings are submitted to the involved agencies. These agencies use the report to meet their agency or corporate requirements. This approach also resolves the concern that mixed messages are transmitted to firefighters and the public.