On March 29, 2015, it happened to one of my own. Capt. Pete Dern was clinging to life following his fall through a roof while performing vertical ventilation at a residential structure fire. Surrounded by neighbors and curious onlookers, the Fresno Fire Department (FFD) and Capt. Dern were breaking news and nationally televised within seconds. Thankfully, just over a year later, Capt. Dern is home recovering from his injuries and making progress every day.
Eight days after the Cortland Incident, a Serious Accident Review Team (SART) was assembled to investigate the incident and other contributing factors to the event. The SART was given the latitude to review all issues and perspectives during their research and investigation. The result was, as Tim Sendelbach put it, “A Playbook for Change.”
In the weeks and months that followed this near-miss tragedy, I recognized several takeaways that were extremely valuable in the management of this incident. I shared these observations because every one of these steps helped all department members work through what will likely be the greatest fire service adversity in our careers. By no means should this information be considered an absolute checklist for management of a catastrophic incident; however, it does offer a start on a path to persevering through an uncommon moment of crisis.
Be present: As a fire chief, you’re committed to the well-being of your members; however, in a critical incident, the physical, mental and emotional aspect of your devotion will be challenged. It will be second nature to want to give members anything you can to help ease them through this kind of crisis. There will be a tremendous amount of information flowing from all sources; this includes hospital, family members and media fronts. For these reasons, consistently being present is essential.
I signed up for the 4 to 8 a.m. time slot to represent the chief officers on “watch duty” at the hospital. And while there may be days (and there were) when your position (chief officer status) may not be embraced by the rank-and-file, stay the course and continue to show up. As the leader, you have to stay above the fray and set the example for others to follow.
In addition to being present, you must also be mindful of looping in your chief officers and city leadership, so they are aware and vigilant, and can assemble forces. Our chief officers did just that, as well as Fresno’s mayor, who was at the hospital within 30 minutes of my phone call. Your job is to make those vital connections and assemble players who will gather resources as quickly as possible.
Place key members off on special assignment: Immediately following Capt. Dern’s incident, five or six members he considered his closest friends were placed off-duty and on special assignment to allow them to focus on supporting Pete and his family without the distractions of work responsibilities. These members were indispensable in planning the logistics of the family and hospital coverage and their presence offered a measure of security to the family that I know Capt. Dern appreciated.
Partner with the local/association: Jointly, fire administration and the FFD Association (Local 753) created an Incident Action Plan (IAP) for daily use, which identified hospital coverage, meals, the Dern’s house maintenance, etc. This approach also ensured that there was one common message when updates were provided to media outlets.
Critical Incident Stress Management (CISM) and checking In: Take care of your people! Within six hours of the incident, we had gathered all members of the first-alarm assignment into a room and started the CISM process. In quick succession, there were two additional CISM meetings with members; one meeting was specifically for the family members of those firefighters affected during this incident. Very soon after the incident, I learned that children of firefighters were telling their dad or mom, “Don’t go to work today!” I am a parent. The natural instinct to comfort and reassure is strong. I did what I could to help my members ease through that process of reassuring their families. Over a period of 120 days after the incident, I called all members of the first-alarm assignment, maybe four to six times each, just to check in on them and ask how their families were doing. I wanted to let them know I cared and was there for them if they needed anything. I believe they appreciated those phone calls of compassion.
Reach out to mentors: I had no practice with this degree of a near-miss experience. Consequently, I reached out to trusted fire chiefs and friends for advice and insight. A valued colleague during this time was retired Fire Chief Mary Beth Michos of Prince William County, VA, who had experienced a LODD during her tenure. Chief Michos called or emailed regularly just to touch base with me. She understood the responsibility and heavy-lifting that was required behind the scenes. To this day, I am very grateful for the shared wisdom of her lessons learned as a fire chief. As you all know, the position of fire chief can be a solitary one. If there is an important take-away from this experience, I would encourage you to reach out to a peer who is managing a pathway through adversity; if all you can do is listen while they talk, then you will have played your part beautifully.
Initiate a Serious Accident Review Team (SART): Within hours of the incident, we had initiated phone calls to our peers asking for assistance in building a SART team, to include a member of the executive board of Local 753. Within eight days, SART team members arrived and began to outline what was to become the Cortland Incident Report. At the time, I knew it would have been less trying, much more painless, and more expedient to limit the SART parameters; however, as fire chiefs, it is our responsibility to make the most difficult choices, and do the right thing—even if it’s uncomfortable.
Grant immunity to all members: As chief, I told all members interviewed regarding the SART investigation to please speak truthfully as they all had immunity from any potential discipline. In this case, discipline would have had absolutely no value on the improvement of future performance. Rather, I wanted members to speak honestly and openly to the SART on cultural behavior in an effort to identify behavioral changes needed and the specific types of education improvements that would be required to enhance the safety of our members.
Intentionally staying out of the SART process: My initial counsel to the SART was that I wanted the report to be authentic and not “swayed” to reflect one thing or another. It was by deliberate intention that I and the deputy fire chief of operations abstained from the SART process, including interviews. Although we were not involved in the process, we were both very aware of when the SART was working at FFD headquarters, conducting interviews, etc. When draft versions of the report were at the 60 and 80 percent completion stages, we sat in on two briefings (five hours each) from the SART. The assistant city manager for the City of Fresno also sat in on the 80 percent version meeting, which was very helpful to share the breadth and depth of work that the FFD had ahead of them to address all of the findings and recommendations of the report.
Keep members informed: Open communication with members throughout various stages of the process combats the rumors that surface during an emotionally packed situation. Using emails from the fire chief to all FFD members was the most direct method of immediate communication.
SART rollout: It was my deliberate intent to rollout the final SART report at FFD Headquarters. Invitations were issued to specific people and members to hear from the SART themselves all of the contents of the report. All FFD chief officers, the executive board of Local 753 and the entire first-alarm assignment members were all invited to attend the four-hour meeting. It was important to me that these members be given the courtesy of hearing it first, and allowed the opportunity to have their questions answered, before the rest of the world read the report. Sharing media opportunities with Local 753 during the rollout was also helpful, as we all shared a common message and no group was pointing fingers at the other.
Follow-through: The implementation of a document such as this is absolute. It is my opinion that there is no fire chief who would put themselves or their members through such a challenging and costly process to not execute the recommendations so clearly identified in the Cortland Report. Some items and behaviors identified in the report could be corrected or changed immediately; some of those changes were made within weeks of Capt. Dern’s incident. Still, many other transformations will take years to be realized. A cultural change will require years of uninterrupted education, training and pressure in order to affect change. My commitment to my members is that together we will work tirelessly to ensure that everyone remains healthy and goes home safe to their families. I will be relentless in my promise.
On March 29, 2015, my immediate gut response was that the core of the FFD would never be the same again; that thought is still uppermost in my mind. When I arrived at the hospital that day, the anguished faces of my fellow members was something I never want to see again. I can honestly say that every day brings to light a difference in the work we’re doing at FFD. I watch as long-accepted practices are shown to be ineffective and/or unsafe and my firefighters are stepping up to educate themselves and their peers. A year ago, the members of the FFD radiated a brotherhood that was unsurpassed with a history of non-injury that spoke to their expertise in the field. I’m proud to say that, today, with the Cortland Incident so fresh in the minds of all members, their solidarity in spirit grows to include a growing and unrelenting protectiveness of each other.
I share these thoughts in the hope that all who read this gather some understanding of the many aspects of managing a near-miss incident. The encouragement and support of fellow chiefs, and the depth of your commitment to your firefighters, will power you through the process.
KERRI L. DONIS currently services as the fire chief of the Fresno, CA, Fire Department. She is a 20-year veteran of the department and promoted up through the ranks, holding the deputy fire chief position for 10 years in all divisions: prevention, investigations, training, and operations. She is a credentialed Chief Fire Officer (CFO), Executive Fire Officer (EFO), California State Fire Marshal Chief Officer and holds a master’s degree in organizational leadership from National University, bachelor’s degree in exercise science from California State University, Fresno, and an associate’s degree in fire science from Fresno City College.
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