Page i

2018

07

July 22, 2019

One Fire Fighter Dies and One Fire Fighter Burned during 

Firefighting Operations at a Grass Fire-Texas 

Executive Summary 

On March 10, 2018, a 68-year-old male volunteer fire

fighter was burned during firefighting operations at a 

grass fire. The fire fighter was transported from the

scene to an Army Medical Center via air ambulance.

The fire fighter died on March 23, 2018 from burn 

injuries sustained at the grass fire. At 1103 hours on 

March 10, a citizen called the county 9-1-1 center to 

report a controlled burn that had grown into a grass fire

was spreading. The county 9-1-1 center dispatched 

Station 5 at 1105 hours to a report of a grass fire. When 

the call was dispatched, a fire fighter (Fire Fighter “A”) 

was in his privately owned vehicle (POV) and 

responded to Station 5. He was wearing jeans, a tee 

shirt, and tennis shoes. Fire Fighter “A” did not have his 

turnout gear or brush gear, which were at home. He 

responded in Grass 5-1 with another fire fighter, who 

was the driver/operator of Grass 5-1. Grass 5-1 arrived 

on scene at 1112 hours. The driver/operator requested 

additional resources from Fire Station 5 and mutual aid 

from county Fire Station 2. Another fire fighter (Fire 

Fighter “B”) from Station 5 responded in his 

POV to the scene. He arrived and parked 

behind Grass 5-1. Fire Fighter “B” parked his 

POV along a fence line and got onto Grass 5-1. 

He was not wearing turnout gear or brush gear, 

only civilian clothing similar to the other fire 

fighter. Both fire fighters were riding in a standing position behind the cab on either side of the water 

tank on Grass 5-1. This area is secured by a locking gate. Grass 5-1 was attempting to extinguish the 

fire in the tree line and fence line while moving north. Grass 5-1 was attacking the fire from the black

(burned grass). A bulldozer was operating north of Grass 5-1. The wind suddenly shifted to the 

northwest, which was blowing smoke on Grass 5-1. The fire moved into the grass (Blue Stem Grass 

and Dallas Grass) that was not burned. As Grass 5-1 was moving, the two fire fighters riding in the 

back shouted for the driver/operator to stop Grass 5-1. The reel line hose was dragging behind Grass 5-

1. Fire Fighter “A” gathered the hose and put the hose over his shoulder. He got back on Grass 5-1 but

didn’t latch the gate. Either the weight of the hose or the hose snagging caused Fire Fighter “A” to fall

off Grass 5-1. Grass 5-1 moved about 15 yards when Fire Fighter “B” shouted to stop. Fire Fighter

The position on Grass 5-1 that the fire fighter 

(Fire Fighter “A”) was riding on when he fell off 

and was overrun by the fire.

(NIOSH Photo.) 
Page ii

One Fire Fighter Dies and One Fire Fighter Burned during 

Firefighting Operations at Grass Fire-Texas 

Report # F2018-07

“A” had stepped into a hole, fell, and could not get up before he was overrun by the fire. The 

driver/operator of Grass 5-1 turned the apparatus around and went back to Fire Fighter “A”. Fire 

Fighter “B” and the driver/ operator got Fire Fighter “A” into the cab of Grass 5-1. They transported

Fire fighter “A” to the Command Post and medical treatment was started on Fire Fighter “A”. A 

county medic unit, Medic 2 arrived and started patient care on Fire Fighter “A” and requested the 

response from an air ambulance. Fire Fighter “A” was transported by air ambulance to an Army 

Medical Center in a Texas metropolitan city. Fire Fighter “A” died on March 23, 2018 from the burn 

injuries sustained at this incident. 

Fire Fighter “B” was treated on scene for burns to his right elbow and right ear. He was also treated

and released at the emergency room at a local hospital for these burns. 

Contributing Factors

• Lack of personal protective equipment

• Apparatus design

• Lack of scene size-up

• Lack of situational awareness

• Lack of training for grass/brush fires

• Lack of safety zone and escape route

• Radio communications issues due to incident location

Key Recommendations 

• Fire departments should ensure fire fighters who engage in wildland firefighting wear personal

protective equipment that meets NFPA 1977, Standard on Protective Clothing and Equipment

for Wildland Firefighting

• Fire departments should comply with the requirements of NFPA 1500, Standard on Fire

Department Occupational Safety, Health, and Wellness Program for members riding on fire

apparatus

The National Institute for Occupational Safety and Health (NIOSH), an institute within the Centers for Disease Control and 

Prevention (CDC), is the federal agency responsible for conducting research and making recommendations for the prevention of 

work-related injury and illness. In 1998, Congress appropriated funds to NIOSH to conduct a fire fighter initiative that resulted in the 

NIOSH Fire Fighter Fatality Investigation and Prevention Program, which examines line-of-duty deaths or on-duty deaths of fire 

fighters to assist fire departments, fire fighters, the fire service, and others to prevent similar fire fighter deaths in the future. The 

agency does not enforce compliance with state or federal occupational safety and health standards and does not determine fault or 

assign blame. Participation of fire departments and individuals in NIOSH investigations is voluntary. Under its program, NIOSH 

investigators interview persons with knowledge of the incident who agree to be interviewed and review available records to develop 

a description of the conditions and circumstances leading to the death(s). Interviewees are not asked to sign sworn statements and 

interviews are not recorded. The agency's reports do not name the victim, the fire department, or those interviewed. The NIOSH 

report's summary of the conditions and circumstances surrounding the fatality is intended to provide context to the agency's 

recommendations and is not intended to be definitive for purposes of determining any claim or benefit.

For further information, visit the program website at www.cdc.gov/niosh/fire or call toll free 1-800-CDC-INFO (1-800-232-4636).
Page 1 

2018

07

July 22, 2019

One Fire Fighter Dies and One Fire Fighter Burned during 

Firefighting Operations at a Grass Fire-Texas 

Introduction 

On March 10, 2018, a 68-year-old male volunteer fire fighter was burned during firefighting operations 

at a grass fire. Fire Fighter “A” was transported from the scene to an Army Medical Center via air 

ambulance. The fire fighter died on March 23, 2018 from his burn injuries sustained at the grass fire. 

On March 26, 2018, the United States Fire Administration notified the National Institute for 

Occupational Safety and Health (NIOSH) of this incident. On April 22 – 25, 2018, an investigator 

from the NIOSH Fire Fighter Fatality Investigation and Prevention Program (FFFIPP) traveled to 

Texas to investigate this incident. The NIOSH investigator met with representatives from the deceased 

fire fighter’s fire department, the mutual aid fire departments that responded to this incident, the 

county sheriff’s office, and the State Fire Marshal’s Office - Texas Department of Insurance. During 

the investigation, witness statements were reviewed and interviews were conducted with the fire 

fighters and officers involved in the incident. The NIOSH investigator also reviewed the training 

requirements for volunteer fire fighters in the state of Texas. During this investigation, the fire 

apparatus used in this incident was inspected and photographed plus the incident scene was visited and 

photographed. 

Fire Department

Fire Station 5, which was formed in 1960, operates with 27 members, serves a population of 600, and 

has a first due response area of 34 square miles. Fire Station 5 responds to 20 – 30 alarms annually. 

Fire Station 5 operates from one fire station and has 1 pumper, 1 tanker (tender), and 2 grass trucks. 

Business meetings are the 1st Wednesday of each month and training is conducted on the 3rd

Wednesday of each month. 

There are 10 volunteer fire departments in the county. The county consists of 960 square miles with a 

population of 25,560. The town where the grass fire occurred is unincorporated. 

Training and Experience

In Texas, all volunteer fire fighter training requirements, certification requirements, and standards are 

determined by each volunteer fire department. Fire Station 5 does not maintain files for each member 

that tracks their training and certifications. Training by the department is recorded on meeting rosters. 

There is no defined process for fire fighters to receive training within the department.

Equipment and Personnel 

On March 10, 2018, county Fire Station 5 was alerted for a grass fire. Two mutual aid fire departments 

were requested by the fire department to respond to assist. The apparatus and personnel from the three 

fire departments directly involved in this incident are shown in the diagram below. (See Diagram 1). 
Page 2 

One Fire Fighter Dies and One Fire Fighter Burned during 

Firefighting Operations at Grass Fire-Texas 

Report # F2018-07

Resource Designation Staffing Time Dispatched On-Scene

Fire Station 5

Grass 5-1 2 fire fighters 1106 Hours 1112 Hours

Grass 5-2 2 fire fighters 1106 Hours 1121 Hours

 Tanker 5 2 fire fighters 1106 Hours 1123 Hours

Engine 5 1 fire fighter 1154 Hours 1202 Hours

Fire Station 2

Grass 2 2 fire fighters 1120 Hours 1134 Hours

Grass 22 2 fire fighters 1120 Hours 1138 Hours

Tanker 2 1 fire fighter and fire chief 1120 Hours 1138 Hours

Fire Station 1

Brush 1 3 fire fighters 1147 Hours 1202 Hours

Apparatus

The two fire fighters (Fire Fighter “A” and Fire Fighter “B”) riding on Grass 5-1 were riding in a 

standing position behind the cab of the apparatus. Grass 5-1 is considered a Type V/Type VI wildland 

engine. These riding positions are located on either side of the apparatus. The driver and passenger 

riding positions are connected by an open walkway (See Photo 1). Access or egress is by opening a 

gate that is secured by lifting the gate and placing the pin in a receiver (See Photo 1). Additionally the 

gate opened outward. Grass 5-1 is a 2012 Ford F550 with a side step configuration. The apparatus has 

a 300 gallon booster tank with 150-foot 1-inch hose on a reel and several short “whip lines” (See 

Photo 1). The apparatus met the requirements of NFPA 1906, Standard for Wildland Fire Apparatus, 

and 2012 edition. 

Diagram 1. The deployment of resources to the grass fire on March 10, 2018
Page 3 

One Fire Fighter Dies and One Fire Fighter Burned during 

Firefighting Operations at Grass Fire-Texas 

Report # F2018-07

Fuel Load

The fuel involved in this incident was primarily Little Bluestem Grass. Most of the grass was between 

knee-high to waist high. Little Bluestem Grass (Schizachyrium scoparium) is a Texas native which has 

moved from the pasture into the home landscape in recent years. Once established, it is a droughtresistant, easy-care clumping grass that is attractive at any season. Little Bluestem Grass performs well 

as an accent in an garden and is also a very good choice for natural settings or wildscapes in the home 

Photo 1. The side step position on Grass 5-1 showing the gate latching 

mechanism and the short hoselines on each sided of the apparatus

(NIOSH Photo.) 
Page 4 

One Fire Fighter Dies and One Fire Fighter Burned during 

Firefighting Operations at Grass Fire-Texas 

Report # F2018-07

landscape. Little Bluestem Grass provides random patches on slopes and dry areas associated with post 

oak and yaupon landscapes, and grows either in full sun or partial shade. Little Bluestem Gras is 

reported to have been the most common grass present in the original Post Oak Savannah and Cross 

Timbers parts of Texas, and is still a major feature of the tallgrass, midgrass and shortgrass prairies of 

Texas. It is suitable for planting throughout most of Texas, except for the very western portions of the 

state. [Texas A&M University 2001] (See Photo 2). 

Timeline 

The following timeline is a summary of events that occurred as the incident evolved. Not all incident 

events are included in this timeline. The times are approximate and were obtained by studying the 

dispatch records, audio recordings, witness statements, and other available information. This timeline 

also lists the changing fire behavior indicators and conditions reported, as well as fire department 

response and fireground operations. All times are approximate and rounded to the closest minute. 

Photo 2. An example of Little Bluestem Grass that was involved in the grass fire 

on March 10. 

Photo from Texas A&M University, Texas Cooperative Extension 
Page 5 

One Fire Fighter Dies and One Fire Fighter Burned during 

Firefighting Operations at Grass Fire-Texas 

Report # F2018-07

Dispatch Communications & Fire 

Department Response

Time Fireground Communications & 

Fireground Operations

County Dispatch Center received a 9-

1-1 call from a homeowner that a

controlled burn was now out of

control.

1103 

Hours

The County Dispatch Center 

dispatched Fire Station 5. 

1105 

Hours

Grass 5-1 enroute to the grass fire. 1108 

Hours

Grass 5-1 arrived on-scene at the 

grass fire. 

1112 

Hours

Grass 5-2 enroute to the grass fire. 1116 

Hours

Tanker 5 enroute to the grass fire. 1117 

Hours

Command requested mutual aid from 

Fire Station 2.

The County Dispatch Center 

dispatched Fire Station 2 to respond to 

grass fire.

1120 

Hours

The driver/operator of Grass 5-1 

assumed Command. Grass 5-1 was 

conducting firefighting operations in 

the northwest section of the property. 

Grass 5-2 arrived on-scene at the 

grass fire.

1121 

Hours

A citizen is operating a bulldozer trying 

to cut a fire line. 

Tanker 5 arrived on scene. 1123 

Hours
Page 6 

One Fire Fighter Dies and One Fire Fighter Burned during 

Firefighting Operations at Grass Fire-Texas 

Report # F2018-07

Dispatch Communications & Fire 

Department Response

Time Fireground Communications & 

Fireground Operations

Grass 2 enroute to the grass fire. 1124 

Hours

The wind changed direction and the grass 

fire enveloped Grass 5-1. Grass 5-1 

reaches the head of the fire and loses sight 

of the bulldozer. 

1126 

Hours

The driver/operator attempts to turn 

around and the wind shifts, causing the 

smoke to obscure his vision. The driver/ 

operator inadvertently turns into the 

unburned grass. The driver/operator 

described the grass as two to three feet tall.

The booster line comes loose and is 

being dragged behind Grass 5-1. Fire 

Fighter “A” gets off Grass 5-1, gets the 

hose, and gets back on Grass 5-1. 

Command calls the County Dispatch 

Center and advised a “man down” at 

the grass fire. 

1127 

Hours

Fire Fighter “A” fell off of Grass 5-1 

and was overrun by the grass fire and 

sustained significant burns. Fire Fighter 

“B” received burns on the right elbow 

and right ear. 

Fire Fighter “A is helped into the cab 

of Grass 5-1 by the driver/operator and 

Fire Fighter “B”. NOTE: Neither fire 

fighter were not wearing any PPE. 

Grass 5-1 requested automatic aid 

from Fire Station 1 for additional 

brush trucks. 

1128 

Hours
Page 7 

One Fire Fighter Dies and One Fire Fighter Burned during 

Firefighting Operations at Grass Fire-Texas 

Report # F2018-07

Dispatch Communications & Fire 

Department Response

Time Fireground Communications & 

Fireground Operations

The County Dispatch Center 

dispatched Fire Station 1 to respond to 

grass fire. 

The County Dispatch Center 

dispatched a county deputy sheriff, 

Unit 819 to the grass fire for a report 

of a “man down” 

1129 

Hours

Grass 22 and Tanker 2 enroute to the 

grass fire. 

1130 

Hours

The County Dispatch Center 

dispatched Medic 1 for a fire fighter 

down. 

1131 

Hours

County Medic 2 responding to the 

injured fire fighter at the grass fire.

EMS Supervisor (EMS3) responding 

to the injured fire fighter. 

1133 

Hours

Grass 5-1 arrived at the Command Post 

with the injured fire fighters. 

Fire fighters from Fire Station 5 start 

basic life support (BLS) care on Fire 

Fighter “A”. Fire Fighter “B” was 

treated for burns on his right elbow and 

right ear.

The County Dispatch Center 

contacted the air ambulance to be on 

standby for response to the injured 

fire fighter at the grass fire. 

Command advised the County 

Dispatch Center of the injured fire 

fighter’s condition. 

Grass 2 arrived at the grass fire.

1134 

Hours

Firefighting operations continue with 

Grass 5-1, Grass 5-2, Grass 2, and 

Grass 22. 
Page 8 

One Fire Fighter Dies and One Fire Fighter Burned during 

Firefighting Operations at Grass Fire-Texas 

Report # F2018-07

Dispatch Communications & Fire 

Department Response

Time Fireground Communications & 

Fireground Operations

The County Dispatch Center advised 

the air ambulance (Air Evac 47) to 

launch. 

Grass 22 and Tanker 2 arrived on 

scene.

1138 

Hours

Fire Fighter 597 from Fire Station 5 

assumed Command of the incident. 

Medic 2 (ALS) arrived at the grass 

fire.

1141 

Hours

The County Dispatch Center 

contacted the Texas Forest Service for 

response to the grass fire. 

1143 

Hours

Advanced life support (ALS) care 

initiated on Fire Fighter “A”. 

The County Dispatch Center paged 

Fire Station 1 to respond to the grass 

fire.

Medic 1 arrived at grass fire.

1147 

Hours

Medic 1 assisted with ALS patient care 

of Fire Fighter “A”.

Brush 1 enroute to the grass fire. 1150 

Hours

Air Evac 47 landed at the scene of the 

grass fire.

1151 

Hours

Engine 5 enroute to the grass fire. 1154 

Hours

The Texas Forest Service advised the 

County Dispatch Center that available 

resources response would be 3 – 4 

hours. Texas Forest Service was 

advised to disregard. 

1155 

Hours

Grass 1 and Engine 5 arrived at the 

grass fire.

1202 

Hours
Page 9 

One Fire Fighter Dies and One Fire Fighter Burned during 

Firefighting Operations at Grass Fire-Texas 

Report # F2018-07

Dispatch Communications & Fire 

Department Response

Time Fireground Communications & 

Fireground Operations

Command advised Air Evac 47 was 

transporting patient to a burn hospital 

in San Antonio. 

1217 

Hours

Fire Fighter “A” loaded into Air Evac 

47. 

Command advised the grass fire in 

under control. “We are in the mop-up 

phase.” 

Medic 1 cleared the scene of the grass 

fire.

1226 

Hours

EMS3 cleared the scene of the grass 

fire. 

1230 

Hours

Grass 1 clear of the grass fire and 

returned to quarters. 

1301 

Hours

Medic 2 cleared the scene of the grass 

fire. 

1328 

Hours

Command advised fire is out and all 

units are clear of the grass fire. 

Command is dissolved. 

1358 

Hours

Personal Protective Equipment

Fire Station 5 provides all members with a Nomex IIIA jumpsuit for grass fires. This garment meets

or exceeds NFPA 1977 Standard on Protective Clothing and Equipment for Wildland Fire Fighting, 

2016 Edition (See Photo 3). The fire department also provides a helmet, gloves, and boots, which are 

used for both structural firefighting and for grass fires. Fire Fighter “A” was not wearing this PPE 

while fighting the grass fire. He was wearing a tee shirt, jeans, and tennis shoes. Also, Fire Fighter 

“B” was not wearing any PPE.

The fire department also provides fire fighters with structural turnout gear which meets the 

requirements of NFPA 1971, Standard on Protective Ensembles for Structural Fire Fighting and 

Proximity Fire Fighting, current edition.
Page 10 

One Fire Fighter Dies and One Fire Fighter Burned during 

Firefighting Operations at Grass Fire-Texas 

Report # F2018-07

Weather Conditions 

On March 10, 2018 at 1115 hours, the temperature was 77 degrees Fahrenheit, the dew point was 66 

degrees Fahrenheit, the relative humidity was 69%, the barometric pressure was 29.82, visibility was 

Photo 3. An example of the jumpsuit that Fire Station 5 provides members to 

wear when fighting grass fires.

https://www.wfgear.com/
Page 11 

One Fire Fighter Dies and One Fire Fighter Burned during 

Firefighting Operations at Grass Fire-Texas 

Report # F2018-07

10 miles, the winds were at 6 miles an hour (MPH), the skies were overcast, and there had been no 

precipitation in the past 24 hours [Weather Underground 2018]. 

Investigation 

At 1103 hours on March 10, a citizen called the county 9-1-1 center to report a controlled burn that 

was now an uncontrolled grass fire and spreading. The citizen had been burning brush piles and the 

wind shifted and ignited the grass (Bluestem Grass) (See Photo 4). 

The county fire dispatch center dispatched Fire Station 5 at 1105 hours for a report of a grass fire. 

When the call was dispatched Fire Figher “A” was in his privately owned vehicle (POV) and 

immediately responded to Station 5. He was wearing jeans, a tee shirt, and tennis shoes. Fire Fighter 

Photo 4. One of the brush piles that the citizen was going to burn when the fire extended 

into the grass. The grass fire burned north to the property line. This picture was taken 7 

weeks after the fire occurred.

(NIOSH Photo) 
Page 12 

One Fire Fighter Dies and One Fire Fighter Burned during 

Firefighting Operations at Grass Fire-Texas 

Report # F2018-07

“A” did not have his turnout gear or brush gear, which was at home. Fire Figher “A” pulled Grass 5-1 

out of the station and was waiting for another fire fighter to arrive at the fire station. Once the fire 

fighter arrived at the fire station, Fire Figher “A” got into the passenger seat of Grass 5-1. The other 

arriving fire fighter functioned as the driver/operator of Grass 5-1. Grass 5-1 responded at 1108 hours 

and arrived on scene at 1112 hours. 

Upon arrival, Grass 5-1 entered a dirt driveway which led to the fire. Grass 5-1 went across a path 

along the tank dam and went directly to the fence line. A citizen was on a tractor cutting the grass in 

the field between the tank dam and the fence line to prevent the fire from moving any further south. 

Fire Fighter “B” from Fire Station 5 arrived on scene behind Grass 5-1 and parked his POV along the 

southeastern fence line. The fire was moving north across the tree line and fence line (See Photo 5).

The fire was in the most eastern part of Fire Station 5’s 1st due area and the county. This created issues 

trying to communicate with the County Dispatch Center and other fire department resources due to 

radios not being able to contact the radio repeater system. 

Photo 5. The solid yellow lines indicate the property boundaries and the area of the grass fire 

which was approximately 10 acres. The red indicates the location of where the fire started.

(Photo from Google Earth.) 
Page 13 

One Fire Fighter Dies and One Fire Fighter Burned during 

Firefighting Operations at Grass Fire-Texas 

Report # F2018-07

The driver/operator of Grass 5-1 assumed Command of this incident. He requested additional 

resources from Fire Station 5, county Fire Station 2, and county Fire Station 1. At this time, the fire 

was approximately 10 acres in size. 

Grass 5-1 began attacking the fire from the burned “black” area. Grass 5-1 was attempting to 

extinguish the fire in the tree line and fence line while moving north. A bulldozer was operating north 

of Grass 5-1. A citizen was operating a private bulldozer independent of the fire department

operations. The bulldozer was attempting to cut a fire break in the very northern part of the property 

ahead of the fire. 

Grass 5-2 arrived on scene at 1121 hours. Another fire fighter from Fire Station 5 had responded in his 

POV to the scene. He got in the cab of Grass 5-2 at the tank dam. Grass 5-2 went east in the field 

towards the fence line. The grass fire was near the POV owned by Fire Fighter “B” on Grass 5-1. 

Grass 5-2 extinguished the fire around the POV and moved north towards Grass 5-1. 

Grass 5-1 reached the head of the fire and lost sight of the bulldozer. The driver/operator of Grass 5-1 

attempted to turn around and the wind shifted, causing the smoke to obscure his vision. The 

driver/operator inadvertently turned into the unburned grass. The driver/operator described the grass as 

two to three feet tall. The time was approximately 1124 hours (See Photo 6). 
Page 14 

One Fire Fighter Dies and One Fire Fighter Burned during 

Firefighting Operations at Grass Fire-Texas 

Report # F2018-07

The wind shift caused the fire to head directly toward Grass 5-1. Grass 5-1 Fire Fighter “B” advised 

the driver/operator to stop because they were dragging the “red line” (booster line). Fire Fighter “A”

and Fire Fighter “B” exited the vehicle to retrieve the hoseline. The driver/operator told them to 

“forget the line” and get back in the truck. Fire Fighter “B” entered the right side (passenger) side step

and Fire Fighter “A” got back Grass 5-1 on the side step behind the driver. Fire Fighter “A” had a 

portion of the red line over his shoulder. When the driver accelerated to exit the area, Fire Fighter “A”

was pulled from the apparatus by the red line that remained on the ground due to the gate not being 

properly latched. Fire Fighter “B” started pounding on the cab of Grass 5-1 to get the driver/operator to 

stop the apparatus. Grass 5-1 traveled approximately 35 – 45 feet before the driver/operator stopped 

the apparatus. The time was approximately 1127 hours. 

Photo 6. The initial firefighting operations with Grass 5-1 and Grass 5-2. The green 

arrows indicate the direction of travel for the brush trucks. The red arrow is the 

direction the fire is traveling. The time is approximately 1124 hours. 

( h f G l h )
Page 15 

One Fire Fighter Dies and One Fire Fighter Burned during 

Firefighting Operations at Grass Fire-Texas 

Report # F2018-07

When Fire Fighter “A” fell off of Grass 5-1, he fell into a hole about 6 – 12 inches deep and was 

overrun by the fire. The driver/operator and Fire Fighter “B” found Fire Fighter “A” in the fire and 

suffering from burns to his face, arms and hands, chest, and legs. They helped Fire Fighter “A” into the 

cab of Grass 5-1 with assistance from the two fire fighters on Grass 5-2. The driver/operator of Grass 

5-1 advised the County Dispatch Center of a “man down”. Once Fire Fighter “A” was in the cab of

Grass 5-1, the driver/operator drove Grass 5-1 to the command post, which was located near Tanker 5.

Fire Fighter “B” was riding the right step position behind the cab of Grass 5-1. The time was

approximately 1129 hours. At 1131 hours, the County Dispatch Center dispatched a county medic unit

(Medic 2) to the scene for an injured fire fighter.

At 1133 hours, a county medic unit – Medic 1 responded to this incident due to time and distance. 

EMS 3, the EMS Supervisor, was dispatched plus Air Evac 47, the air ambulance was placed on 

standby at 1133 hours. Grass 5-1 arrived at the Command Post at approximately 1133 hours. Fire 

Fighter “A” was helped out of the cab of Grass 5-1 by department fire fighters and placed on a turnout 

coat on the ground. Basic life support (BLS) care was initiated on Fire Fighter “A” by fire department 

members. 

While patient care continued on Fire Fighter “A” by fire fighters from, Grass 2 arrived on scene at 

1134 hours. At this time, Grass 5-1, Grass 5-2, and Grass 2 are continuing firefighting operations in the 

field northwest of the command post and along most of the property fence line. The driver/operator of 

Grass 5-1 filled the booster tank with water from Tanker 5 before resuming firefighting operations. 

At 1138 hours, Unit 597 from Fire Station 5 assumed Command of the incident. Command advised the 

County Dispatch Center to launch the air ambulance (Air Evac 47). Grass 22 and Tanker 2 arrived on 

scene on the property west of the fence line. Grass 2 assisted with controlling the grass fire along the 

fence line. 

Medic 2 arrived on scene at 1141 hours and initiated advanced life support (ALS) care on Fire Fighter 

“A” at 1143 hours. Medic 1 arrived at 1147 and assisted with ALS care. The County Dispatch Center 

contacted the Texas Forest Service to respond with personnel and resources to this incident. Also, the 

County Dispatch Center dispatched Fire Station 1 to this incident. At 1150 hours, Brush 1 from Fire 

Station 1 responded to the grass fire with three fire fighters. At 1151 hours, Air Evac 47 landed at the 

scene.

The firefighting operations continue in the field with Grass 5-1 (two fire fighters), Grass 5-2 (two fire 

fighters), Grass 2 (two fire fighters), and Grass 22 (two fire fighters) primarily focused in the middle of 

the field and along the fence line (See Photo 7). 
Page 16 

One Fire Fighter Dies and One Fire Fighter Burned during 

Firefighting Operations at Grass Fire-Texas 

Report # F2018-07

At 1155 hours, the Texas Forest Service advised that available resources had a 3 – 4 hour response. 

The County Dispatch Center advised the Texas Forest Service to disregard the request. At 1202 hours, 

Grass/Brush 1 and Engine 5 arrived on scene. At 1217 hours, Command advised the County Dispatch 

Center that Air Evac 47 was enroute to a burn hospital in San Antonio. 

At 1226 hours, Command advised the fire dispatcher that the grass fire was under control and crews 

were operating in the mop-up phase (See Photo 8). Command advised the County Dispatch Center that 

the fire was out and all units were clearing the scene at 1358 hours. 

Photo 7. The firefighting operations continued while the injured fire fighter was being 

treated by EMS. The green arrows indicate the direction of travel of the brush trucks. The 

red arrow indicates the direction of fire and smoke travel. The time was approximately 1152 
Page 17 

One Fire Fighter Dies and One Fire Fighter Burned during 

Firefighting Operations at Grass Fire-Texas 

Report # F2018-07

Grass 5-1 Fire Fighter ”B” was treated on scene for burns to his right elbow and right ear. He was also 

treated and released at the emergency room at a local hospital for these burns.

Grass 5-1 Fire Fighter “A” was transported to an Army Medical Center Emergency Department by Air 

Evac 47, an air medical ambulance service. Grass 5-1 Fire Fighter “A” was stabilized and transferred 

Photo 8. A picture taken by a county deputy sheriff from the Command Post. The view is 

looking due west across the tank dam, the fence line, and to adjacent farm. The white pickup truck belongs to Fire Fighter “B”. A civilian operated the tractor and cut (shredded) the 

grass between tank dam and the fence line. The time was approximately 1309 hours. The 

majority of the grass fire has been extinguished.

(Photo courtesy of the County Sheriff’s Office.) 
Page 18 

One Fire Fighter Dies and One Fire Fighter Burned during 

Firefighting Operations at Grass Fire-Texas 

Report # F2018-07

to the Burn Unit/ICU. On March 23, 2018, Grass 5-1 Fire Fighter “A” succumbed to his injuries and 

was pronounced deceased. An autopsy was conducted by the local county Medical Examiner’s Office.

Contributing Factors

Occupational injuries and fatalities are often the result of one or more contributing factors or key 

events in a larger sequence of events that ultimately result in the injury or fatality. NIOSH 

investigators identified the following items as key contributing factors in this incident that ultimately 

led to the fatalities:

• Lack of personal protective equipment

• Apparatus design

• Lack of scene size-up

• Lack of situational awareness

• Lack of training for grass/brush fires

• Lack of safety zone and escape route

• Radio communications issues due to incident location

Cause of Death

According to the death certificate, the medical examiner listed the victim’s cause of death as

complications due to thermal injuries. The manner of death was accidental. 

Recommendations 

Recommendation #1: Fire departments should ensure fire fighters who engage in grass or brush 

firefighting operations wear personal protective equipment that meets NFPA 1977, Standard on 

Protective Clothing and Equipment for Wildland Firefighting. 

Discussion: The fire department involved in this incident provides all members with both structural 

turnout gear and wildland firefighting gear. The department’s Standard Operation Procedure (SOP), 

Section 1 - Protective Clothing, states: “The level of protective clothing required depends on the type 

of call, and the operations involved, as outlined in specific SOPs.” However there is no additional SOP 

addressing the level of protective clothing required other than during vehicle fires and structural

firefighting operations. 

Fire fighters involved in wildland firefighting activities should be provided, at a minimum, the 

personal protective equipment (PPE) as described by NFPA 1977, Standard on Protective Clothing 

and Equipment for Wildland Fire Fighting [NFPA 2016a]. NFPA 1977 covers compliant PPE and

clothing specific to wildland firefighting, including fire resistant shirts and pants, gloves, boots, and 

helmet. The goal of this PPE is to protect fire fighters against adverse environmental effects during 

wildland firefighting operations. Also, NFPA 1977 compliant PPE provides radiant heat protection for 

the wildland fire fighter using flame-resistant clothing and equipment without causing excessive 

internal heat stress.
Page 19 

One Fire Fighter Dies and One Fire Fighter Burned during 

Firefighting Operations at Grass Fire-Texas 

Report # F2018-07

NFPA 1500, Standard on Fire Department Occupational Safety, Health, and Wellness Program states 

in Paragraph 7.7.2,“Members who engage in or are exposed to the hazards of wildland firefighting 

operations shall be provided with and use protective garments and protective equipment that meet the 

requirements of NFPA 1977” [NFPA 2018]. 

All fire fighters who respond to wildland fires should be provided with and use NPFA compliant 

protective clothing that is designed for the unique conditions found in wildland firefighting

operations. 

At this incident, the fire department provided each member with PPE for wildland incidents. The two 

fire fighters riding on Grass 5-1 responded to the grass fire in civilian clothing and had no PPE. 

Recommendation #2: Fire departments should comply with the requirements of NFPA 1500, 

Standard on Fire Department Occupational Safety, Health, and Wellness Program for members 

riding on fire apparatus. 

Discussion: NFPA 1500, Standard on Fire Department Occupational Safety, Health, and Wellness

addresses the riding on fire apparatus in Chapter 6 - Fire Apparatus, Equipment, and 

Drivers/Operators, Section 6-3: Riding in Fire Apparatus. The intent of the requirements in Section 

6.3 is to ensure for the safety of all members riding on any type of fire apparatus and to prevent an 

incident such as the one investigated in this report.

The following are requirements regarding riding on fire apparatus from NFPA 1500, Chapter 6: 

• 6.3.1* All persons riding in fire apparatus shall be seated and belted securely by seat belts in

approved riding positions at any time the vehicle is in motion other than as allowed in 6.3.4,

6.3.5, and 6.3.6.

• *A.6.3.1 Fire fighters cannot be allowed to ride on the outside of apparatus in order to fight

wildland fires. The Risk Management Committee (RMC) of the National Wildfire Coordinating

Group (NWCG) represents the U.S. Forest Service, Bureau of Land Management, Bureau of

Indian Affairs, U.S. Fish and Wildlife Service, National Park Service, National Association of

State Foresters, Intertribal Timber Council, International Association of Fire Chiefs, and the

U.S. Fire Administration. Their position is that the practice of fire fighters riding on the outside

of vehicles and fighting wildland fires from these positions is very dangerous, and they strongly

recommend this not be allowed. One issue is the exposure to personnel in unprotected

positions. Persons have been killed while performing this operation. Also, the vehicle driver's

vision is impaired. The second issue is that this is not an effective way to extinguish the fire, as

it can allow the vehicle to pass over or by areas not completely extinguished. Fire can then flare

up underneath or behind the vehicle and could cut off escape routes. The RMC and the NWCG

strongly recommend that two fire fighters, each with a hose line, walk ahead and aside of the

vehicle's path, both fire fighters on the same side of the vehicle (not one on each side), in clear

view of the driver, with the vehicle being driven in uninvolved terrain. This allows the fire

fighters to operate in an unhurried manner, with a clear view of fire conditions and the success
Page 20 

One Fire Fighter Dies and One Fire Fighter Burned during 

Firefighting Operations at Grass Fire-Texas 

Report # F2018-07

of the extinguishment. Areas not extinguished should not be bypassed unless follow-up crews 

are operating behind the lead unit and there is no danger to escape routes or to personnel. 

• 6.3.2 Standing or riding on tail steps, sidesteps, running boards, fully enclosed personnel areas,

or in any other exposed position shall be specifically prohibited [NFPA 2018].

The two fire fighters riding on Grass 5-1 were riding in a standing position behind the cab of the 

apparatus. These riding positions are located on either side of apparatus – driver and passenger

connected by an open walkway. Grass 5-1 was not equipped with belts or tethering for fire fighters 

riding in the standing position. Access or egress is by opening a gate that is has secured by lifting the 

gate and placing the pin in a receiver. Additionally the gate opened outward. Grass 5-1 is a 2012 Ford 

F550 with a side step configuration. The apparatus met the requirements of NFPA1906, Standard for 

Wildland Fire Apparatus, 2012 edition. This apparatus is considered a Type V/Type VI wildland 

engine [NFPA 2012]. 

On August 17, 2017, a tentative interim amendment (TIA) was issued for NFPA 1906, Standard for 

Wildland Fire Apparatus, 2016 edition with an effective date of September 4, 2017. The TIA 

referenced the following: 2.3.8, 14.1.1, 14.4, A.14.4, A.14.4.3.4, A.14.1.1 (new), and E.1.2.4. 

NFPA 1906 Paragraph 14.1.1 now reads, “Each crew riding position shall be within a fully enclosed 

personnel area.” 

A.14.1.1 states, “Typically, while engaged in firefighting operations on structural fires, apparatus are

positioned in a safe location, and hose is extended as necessary to discharge water or suppressants on

the combustible material.” In wildland fire suppression, mobile attack is often utilized in addition to

stationary pumping. In mobile attack, sometimes referred to as “pump-and-roll,” water is discharged

from the apparatus while the vehicle is in motion. Pump-and-roll operations are inherently more

dangerous than stationary pumping because the apparatus and personnel are in close proximity to the

fire combined with the additional exposure to hazards caused by a vehicle in motion, often on uneven

ground. The personnel and/or apparatus could thus be more easily subject to injury or damage due to

accidental impact, rollover, and/or environmental hazards, including burn over.

To potentially mitigate against the increased risk inherent with pump-and-roll operations, the 

following alternatives are provided for consideration: 

(1) Driver and fire fighter(s) are located inside the apparatus in a seated, belted position within the

enclosed cab. Water is discharged via a monitor or turret that is controlled from within the

apparatus.

(2) Driver and fire fighter(s) are located inside the apparatus in a seated, belted position within the

enclosed cab, but water is discharged with a short hose line or hard line out an open cab window.

(3) Driver is located inside the apparatus in a seated, belted position within the enclosed cab with one

or more fire fighters seated and belted in the on-board pump-and-roll firefighting position as

described in a following section.

(4) Driver is located inside the apparatus in a seated, belted position within the enclosed cab. Fire
Page 21 

One Fire Fighter Dies and One Fire Fighter Burned during 

Firefighting Operations at Grass Fire-Texas 

Report # F2018-07

fighter(s) is located outside the cab, walking alongside the apparatus, in clear view of the driver, 

discharging water with a short hose line. 

Under no circumstances is it ever considered a safe practice to ride standing or seated on the exterior

of the apparatus for mobile attack other than seated and belted in an on-board pump-and-roll 

firefighting position. [2016b]. 

The on-board pump-and-roll firefighting position should only be used when the following conditions 

are met:

1. The apparatus is actively engaged in mobile attack on the fire line,

2. The fuel model is characterized as fine fuels, which create hazardous fuel conditions in

wildland urban interface areas.

3. The ground is level, flat, and free of obstacles,

4. Driver visibility is unobstructed,

5. Vehicle speeds are no greater than 10 mph, and

6. Fire fighters are wearing full protective NFPA 1977-compliant personal protective equipment

and are equipped with a fire shelter.

Development of this Design. 

Firefighting is an inherently dangerous operation. This is especially true of fighting a moving 

wildland fire in fine fuels. There are many techniques used and a great deal of discussion about the 

safest way to fight these fires. Over the years, many fire companies and apparatus manufacturers have

developed techniques and equipment for fighting wildland fine fuel fires. These have included fighting 

fire from seats mounted to front bumpers, sitting on hoods or hose reels, standing on flat beds, 

standing in step wells on the side of apparatus, or standing on running boards. All of these approaches 

are extremely dangerous. The Fire Department Apparatus Technical Committee did extensive work to 

try to come up with a safer solution based upon the available apparatus and techniques that have been 

historically used in the industry. The preceding suggestions are safer than any of these ad-hoc 

techniques. The NFPA Fire Service Occupational Safety and Health Technical Committee does not 

approve of any fireground operations that permit the fire fighter to ride outside the fully enclosed cab 

of a moving apparatus [NFPA 2018]. 

At this incident, neither fire fighter riding on Grass 5-1 were wearing PPE, neither fire fighter was 

seated and secured by a seat belt, and the gate protecting the fire fighters on Grass 5-1 opened outward. 

Recommendation #3: Fire departments should ensure that the incident commander develops and 

communicates the strategy and incident action plan (tactics) during the initial stages of the incident. 

The incident action plan should be updated when benchmarks are met/not met. 

Discussion: Brush or grass firefighting operations are very dynamic and fast-paced. An incident 

commander must determine a strategy and then develop the incident action plan (IAP) to ensure that 

the proper actions to take control of the incident. The incident commander must follow the decision 
Page 22 

One Fire Fighter Dies and One Fire Fighter Burned during 

Firefighting Operations at Grass Fire-Texas 

Report # F2018-07

making model that includes identifying incident critical factors (through a situational evaluation or 

“size up”), consider the standard risk management plan, declare the strategy (offensive or defensive),

and then set tactical objectives. This model will lead to the development of the IAP, which serves as 

the tactical road map to effectively manage the incident. The IAP defines where and when resources 

will be assigned throughout the incident, along with tasks and objectives [NFPA 2014]. 

To ensure a standard outcome of each incident, the incident commander should match the standard 

conditions to standard actions. This is the core of the incident command system and is the basis for all 

operations. Standard conditions are identified as the incident’s current critical factors: 

• Identify the incident’s critical factors, which can include type of incident, type of occupancy,

life safety considerations, etc., before taking any action.

• Initial and ongoing size-up of the incident’s critical factors must produce the information that

becomes the basis for the current incident strategy and IAP.

• Current, accurate, and relevant information provides the foundation for effective initial and

ongoing action.

• The goal of this systematic evaluation process continually produces standard, safe, wellmanaged incident outcomes [Blue Card 2018].

The IAP should match the defined strategy established by an incident commander for a particular 

incident. The defined strategy describes the overall approach to incident operations and drives the IAP. 

The IAP provides the tactical assignments required to achieve the offensive/defensive objectives. The 

order of occurrence is key—the strategic goals are developed first and then followed by the tactical 

objectives. At each incident, the incident commander should start with a standard placement-oriented 

operational plan that develops a strong, dependable beginning for command and control of the 

incident. While developing the strategic goal for the incident is the first component, the incident 

commander needs to produce detailed tactical objectives that can be assigned to responding companies. 

This is the purpose of the IAP [Brunacini 2002; Fire and Rescue Departments of Northern Virginia 

2013]. 

The initial incident commander, most often, is a company officer who arrives on-scene prior to a chief 

officer. The company officer should provide a detailed size-up, which is communicated to all 

responding resources including the dispatch center. The company officer assumes command and 

makes a decision regarding the strategy and IAP. The company officer may not have the ability or time 

to record the IAP on paper and provide documentation when transferring command. In this case, a 

verbal IAP is appropriate. As with this or any incident, events can occur very quickly before a detailed 

tactical worksheet or written IAP is developed [Brunacini 2002]. 

The IAP can be as simple as a verbal transmission to all units assigned to an incident. Once an officer 

assumes command, the overall strategy – either offensive or defensive is communicated. Command 

can make specific assignments to arriving companies along with tactical objectives such as search, 

rescue, fire attack, ventilation, utility control, and exposure protection. The responding chief officer 

should be monitoring radio communications and documenting tactical objectives on a tactical 
Page 23 

One Fire Fighter Dies and One Fire Fighter Burned during 

Firefighting Operations at Grass Fire-Texas 

Report # F2018-07

worksheet if possible. When the chief officer arrives on-scene, an update from the initial incident 

commander can occur (face-to-face or by radio). The chief officer will then assume command at a 

stationary location. By following this process, the initial and subsequent incident commanders will be 

in a stronger position to manage an incident should an emergency event occur [NFPA 2014]. 

NFPA 1561 defines an IAP as a verbal plan, tactical worksheet, written plan, or combinations thereof 

that reflects the overall incident strategy, tactics, risk management, and member safety that are 

developed by an incident commander. NFPA 1561, Standard on Emergency Services Incident 

Management System and Command Safety [NFPA 2014] requires the following regarding an incident 

action plan: 

• 5.3.12.1 The incident commander shall be responsible for developing and/or approving an

incident action plan (IAP).

• 5.3.12.2 This IAP shall be communicated to all staged and assigned members at an incident.

• 5.3.20 The incident commander shall be responsible for reviewing, evaluating, and revising the

IAP and overall strategy of the incident (See Diagram 2).

At this incident, the driver of Grass 5-1 assumed Command of the incident at 1120 hours, which was 

later transferred to the driver of Tanker 5. It is imperative the incident commander develop and 

announce the strategy and incident action plan. 
Page 24 

One Fire Fighter Dies and One Fire Fighter Burned during 

Firefighting Operations at Grass Fire-Texas 

Report # F2018-07

Recommendation #4: Fire departments should ensure that the principles of fireground risk 

management are implemented and followed at all incidents.

Discussion: While it is recognized that firefighting is an inherently hazardous occupation, established 

fire service risk management principles are based on the philosophy that greater risks will be assumed 

when there are lives to be saved and the level of acceptable risk to fire fighters is much lower when 

only property is at stake. Established risk management principles suggest that more caution should be 

exercised in situations where there is no clear evidence indicating a life safety issue or property is 

threatened. Risk management is one of the most important tools fire fighters can use to help reduce the 

Diagram 2. A guide for developing an incident action plan at Type V and Type IV 

incidents. For these types of incidents, the incident action plan is most often 

communicated verbally. 

 (Courtesy of FireFighterCloseCalls.com.) 
Page 25 

One Fire Fighter Dies and One Fire Fighter Burned during 

Firefighting Operations at Grass Fire-Texas 

Report # F2018-07

level of risk to responders operating at a fire. The incident commander must consider all factors and 

their associated risks prior to committing crews to firefighting operations [Chadwick 2014]. 

At any incident, life safety is always the 1st priority, followed by incident stabilization (2nd priority) 

and then property conservation (3rd priority). The ability to ensure for the safety of fire fighters is a 

continuous process throughout the incident. A sound risk management plan ensures that the risks are 

evaluated and matched with the actions and conditions. The incident commander should use the 

following risk management principles: 

• Activities that present a significant risk to the safety of fire fighters shall be limited to situations

that have the potential to save endangered lives.

• Activities that are routinely employed to protect property shall be recognized as inherent risks

to the safety of fire fighters, and the actions shall be taken to reduce or avoid these risks.

• No risk to the safety of fire fighters shall be acceptable where there is no possibility to save

lives or property [Brunacini 2002].

NFPA 1500, Standard on Fire Department Occupational Safety, Health, and Wellness, Chapter 8 – 

Emergency Operations, Section 8.4, Risk Management During Emergency Operations, Paragraph 

A.8.4.2.1 states, “The risk to fire department members is the most important factor considered by the

incident commander in determining the strategy that will be employed in each situation. The

management of risk levels involves all of the following factors:

1. Routine evaluation of risk in all situations,

2. Well-defined strategic options,

3. Standard operating procedures,

4. Effective training,

5. Full protective clothing ensemble and equipment,

6. Effective incident management and communications,

7. Safety procedures and safety officers,

8. Backup crews for rapid intervention,

9. Adequate resources,

10. Rest and rehabilitation,

11. Regular evaluation of changing conditions.

12. Experience based on previous incidents and critiques” [NFPA 2018].

A vital component in a successful risk management program involves the development of a proactive 

and aggressive training program with a focus on the identification of risks and hazards during size-up, 

the ability to maintain situational awareness throughout the life of the incident, and the capability to 

execute fireground survival procedures when placed in a deadly situation. Rare are the instances in 

which fire fighters find themselves in a life-threatening situation, but it is at this time when survival 

training can prove so very valuable. 
Page 26 

One Fire Fighter Dies and One Fire Fighter Burned during 

Firefighting Operations at Grass Fire-Texas 

Report # F2018-07

As with any firefighting operation, the scene size-up is critical component for ensuring a successful 

outcome. The United States Department of Forestry has a five-step risk management process for 

wildland firefighting:

Step 1 – Situation Awareness

• Gather information

o Objectives

o Communications

o Who’s in charge?

o Previous Fire Behavior

o Weather Forecast

o Local Factors

• Scout the Fire

Step 2 – Hazard Assessment

• Estimate Potential Fire Behavior Hazards

o Look Up/Down/Around Indicators

• Identify Tactical Hazards

o Watch Outs

• What other safety hazards exist?

• Consider Severity vs. probability

Step 3 – Hazard Control

• Fire Orders->LCES Checklist- MANDATORY

o Anchor Point

o Downhill Checklist (if applicable)

• What other controls are necessary?

Step 4 – Decision Point

• Are controls in place for identified hazards?

o NO- Reassess situation YES- Next Question

• Are selected tactics based on expected fire behavior?

o NO- Reassess situation YES- Next Question

• Have instructions been given and understood?

o NO- Reassess situation YES- Initiate Action

Step 5 - Evaluate 

• Personnel

o Low experience level with local factors?

o Distracted from primary task?

o Fatigue or stress reaction?

o Hazardous attitude?

• The Situation:
Page 27 

One Fire Fighter Dies and One Fire Fighter Burned during 

Firefighting Operations at Grass Fire-Texas 

Report # F2018-07

o What is changing?

o Are strategy and tactics working [NWCG 2018a]?

This information provides the necessary foundation for fighting a grass or wildland fire. As with 

structural firefighting, there are necessary steps to take to ensure for the successful outcome of an 

incident, but most importantly ensure for the safety of all fire fighters (NWCG 2018a). 

Wildland fire operations should be conducted from the burned or “black” portion of the fire ground. 

With the majority of the fuel already consumed this provides a safe area to operate and a safe escape 

route. The Texas A&M Forest Services provides training and videos for fire departments. The Attack 

from the Black training video encourages firefighters to think ahead—not just in the moment—while 

fighting wildfires, and stresses the importance of wearing proper PPE. The video is available to fire 

departments across the country at no charge. Note: The training video stresses the importance of 

wearing proper personal protective equipment (PPE). The DVD includes fire re-enactment on sand 

tables, which are proven training tools used by the Texas Forest Service. This learning tool helps 

firefighters think about initial attack strategies, contingency plans, and safety zones. The DVD is 

available by sending an email to: AttackFromTheBlack@tfs.tamu.edu requesting a DVD and include 

your name, fire department name and mailing address. 

At this incident, Grass 5-1 arrived on the scene and immediately went to the fence line of the property 

and started firefighting operations. This location created issues with radio communications. Grass 5-1 

moved to the far east side of the property. The driver of Grass 5-1 assumed Command of the incident 

at 1120 hours, which was later transferred to the driver of Tanker 5. 

It is imperative the incident commander develop and announce the strategy and incident action plan. 

Recommendation #5: Fire departments should ensure that an incident commander utilizes the three 

levels of the command structure at incidents based upon the size and complexity of an incident. 

Discussion: An incident commander should ensure that the Incident Command System (ICS) 

organization is developed at a pace that stays ahead of the tactical deployment of personnel and resources at 

an incident. In order for the Incident Commander to manage the incident, they must first be able to direct, 

control, and track the position and function of all resources. Building an ICS organization is the best 

support mechanism the Incident Commander can utilize to achieve the balance between managing 

personnel and incident needs. Simply put, this means: 

• Large scale and complex incidents = Large ICS organization;

• Small scale and “simple” incidents = Small ICS organization.

The basic configuration of command includes three levels: 

• Strategic level – Overall direction of the incident,

• Tactical level – Assigns operational objectives,

• Task level – Specific tasks assigned to companies (FIRESCOPE 2015].
Page 28 

One Fire Fighter Dies and One Fire Fighter Burned during 

Firefighting Operations at Grass Fire-Texas 

Report # F2018-07

The strategic level involves the overall command of the incident. The incident commander (IC) is 

responsible for the strategic level of the ICS organization. The incident action plan should cover all 

strategic responsibilities, all tactical objectives, and all support activities needed during the entire 

operational period. The incident action plan defines where and when resources will be assigned to the 

incident to control the situation. This plan is the basis for developing an ICS organization, assigning all 

resources, and establishing tactical objectives [FIRESCOPE 2015]. 

The tactical level directs operational activities towards specific objectives. Tactical level officers 

include branch directors, division/group supervisors, who are in charge of specific resources. Tactical 

level officers are responsible for specific geographic areas or functions, and supervising assigned 

personnel. A tactical level assignment comes with the authority to make decisions and assignments, 

within the boundaries of the overall plan and safety conditions. The accumulated achievements of 

tactical objectives should accomplish the strategy as outlined in the incident action plan [FIRESCOPE 

2015]. 

The task level refers to those activities normally accomplished by individual companies or specific 

personnel. The task level is where the work is actually done. Task level activities are routinely 

supervised by company officers. The accumulated achievements of task level activities should 

accomplish tactical objectives [FIRESCOPE 2015]. 

Each of these levels is distinct and has their own set of responsibilities. For the majority of incidents 

that fire departments respond to, the initial responsibility for managing all three organizational levels is 

handled by the initial IC, which is most often a company officer. The first arriving officer will assume 

the role as incident commander and will size-up the incident’s critical factors, declare the incident 

strategy, assume Command, and communicate the incident action plan. The IC has initial command 

and control responsibility for the entire incident operation on the strategic level until command is 

transferred or terminated. On the tactical level, the fast attacking IC will implement and execute an 

incident action plan that addresses the incidents critical factors in order to facilitate the completion of 

the tactical priorities [Blue Card 2018]. 

A fast attacking company officer IC will also directly supervise and assist their crew members with the 

tasks required to bring the incident’s problems under control. In most cases, this initial attack wave 

eliminates the incident hazards. For incidents that are not quickly controlled, are escalating, or are 

significant in scope and size upon arrival of the fire department, the strategic and tactical operational 

levels should be upgraded with a chief officer. 

The strategic level of command on these types of incidents will be the 1st operational level that is 

upgraded. This command transfer significantly improves the IC’s position and ability to perform and 

manage the 8 Functions of Command and the corresponding strategic safety requirements for the entire 

incident operation. Placing the IC in a standard command post (CP) position where they can 

exclusively focus on incident management, enhances and facilitates both the completion of the tactical 
Page 29 

One Fire Fighter Dies and One Fire Fighter Burned during 

Firefighting Operations at Grass Fire-Texas 

Report # F2018-07

priorities (the incident action plan) and fire fighter task level safety [Blue Card 2018]. The 8 Functions 

of Command are: 

• Deployment

• Assume, Confirm and the Positioning of Command

• Situation Evaluation

• Strategy and Incident Action Planning

• Communications

• Organization

• Review, Evaluate, Revise

• Continue, Support, & Terminate Command [Blue Card 2018].

The first fire department member to arrive at the scene shall establish command of the incident. The 

initial incident commander shall remain in command until command is passed, transferred or the 

incident is stabilized and terminated: 

• The first member on the scene must initiate the parts of ICS necessary to effectively manage

the incident.

• For incidents that require the commitment of multiple companies, the first member on the scene

must establish and announce “Command”, and initiate an ICS organization appropriate for the

incident. This includes accountability and the SAFETY of members working under Command.

• When a chief officer arrives at the scene at the same time as the initial arriving company, the

chief officer should establish command of the incident [FIRESCOPE 2015].

It is the responsibility of Command to develop an organizational structure, using standard operating 

procedures, to effectively manage the incident scene. The development of the organizational structure 

should begin with deployment of the first arriving fire department unit and continue through a number 

of phases, depending on the size and complexity of the incident. In order for the incident commander 

to manage the incident, they must first be able to direct, control, and track the position and function of 

all operating companies [NFPA 2014]. 

At this incident, the driver of Grass 5-1 assumed Command of the incident at 1120 hours and 

maintained Command until relieved at 1138 hours. 

It is imperative that the incident commander develop and announce the strategy and incident action 

plan. 

Recommendation #6: Fire departments should operate a personnel accountability system to account 

for all fire fighters and first responders assigned to any incident.

Discussion: A personnel accountability system is a system that readily identifies both the location and 

function of all members operating at an incident scene [NFPA 2014]. The philosophy of the personnel 

accountability system starts with the same principles of an incident management system—company 
Page 30 

One Fire Fighter Dies and One Fire Fighter Burned during 

Firefighting Operations at Grass Fire-Texas 

Report # F2018-07

unity and unity of command. Unity can be fulfilled initially and maintained throughout the incident by 

documenting the situation status and resource status on a tactical worksheet. 

An integral part of the accountability system is to make sure that the fire fighters who are assigned and 

operating in the hazard zone are accounted for, starting with the initial operations through the entire 

incident. Also, a process should be in place to periodically check to make sure that all members 

operating in the hazard zone are accounted for by this system. 

One of the most important functions of command safety is for the incident commander to initiate a 

personnel accountability system that includes the functional and geographical assignments at the 

beginning of operations until the termination of the incident. NFPA 1561, Standard on Emergency 

Services Incident Management System and Command Safety, states in Paragraph 8.12.4, “The incident 

commander and members who are assigned a supervisory responsibility that involves three or more 

companies or crews under their command shall have an additional member(s) (e.g., staff aide) assigned 

to facilitate the tracking and accountability of the assigned companies or crews” [NFPA 2014]. 

A functional personnel accountability system requires the following: 

• Development and implementation of a departmental SOP

• Necessary components and hardware, such as an accountability board, individual name tags,

and company name tags

• Training for all members on the operation of the system

• Strict enforcement during emergency incidents.

A functional personnel accountability system should: 

• Be able to identify all members operating in the hazard zone (who)

• Be able to identify where all members are in the hazard zone (where)

• Be able to identify the conditions in the hazard zone (conditions)

• Be able to identify what actions are being taken in the hazard zone (actions)

• Be able to identify paths of access and egress in and out of the hazard zone (exits)

• Be able to identify and assign rapid intervention crew(s) (RIC).

There are many different methods and tools for resource accountability. Some examples are: 

• Tactical worksheets

• Command boards

• Apparatus riding lists

• Company responding boards

• Electronic bar-coding systems

• Accountability tags or keys (e.g., PASSPORT System) [NFPA 2014].

Resource accountability should be assigned to personnel who are responsible for maintaining the 

location and status of all assigned resources at an incident. As the incident escalates, resource status 

would be placed under the Planning Section. This function is separate from the role of the incident 

commander. The incident commander is responsible for the overall command and control of the 
Page 31 

One Fire Fighter Dies and One Fire Fighter Burned during 

Firefighting Operations at Grass Fire-Texas 

Report # F2018-07

incident. Due to the importance of responder safety, resource status should be assigned to a dedicated 

member as the size and complexity of the incident dictates. A number of positions could function in 

this role including an incident command technician, staff assistant, chief officer, or other designated 

member. As the incident escalates and tactical-level management components (e.g., divisions or 

groups) are assigned, the resource status officer (accountability officer) works with the division or 

group supervisors to maintain an on-going tracking and accountability of members [FIRESCOPE 

2015]. A properly initiated and enforced personnel accountability system enhances fire fighter safety 

and survival. It is vital that resources can be identified and located in a timely manner. 

An important aspect of a personnel accountability system is the personnel accountability report (PAR). 

A PAR is an organized on-scene roll call in which each supervisor reports the status of their crew when 

requested by the incident commander [NFPA 2014]. The PAR should be conducted every 15–20 

minutes or when benchmarks are met. 

In order for the personnel accountability system to properly function, the process should include a 

standard operating procedure that defines each function’s responsibility and the necessary hardware 

required to ensure this process is successful on the fireground. Also a training component—both 

classroom and practical—should be conducted to ensure this process functions properly during 

emergency incidents.

At this incident, a personnel accountability system was never established or used. Each mutual aid fire 

department had little or no contact with Command from a personnel accountability standpoint.

Recommendation #7: Lookouts, communications, escape routes, and safety zones (LCES) should be 

established and communicated to all fire fighters during wildland firefighting operations. 

Discussion: In the wildland fire environment establishing and utilizing Lookouts, Communications, 

Escape Routes, and Safety Zones (LCES) are critical to ensure the safety of wildland fire fighters (See 

Appendix One). This includes selecting a lookout or lookouts, setting up a communication system, 

choosing escape routes, and selecting a safety zone(s). LCES is built on two guidelines: before safety 

is threatened, each firefighter must know the LCES system will be used, and LCES must be 

continuously reevaluated as fire conditions change. Note: LCES works well in in other emergency 

responses such as hazardous materials mitigation, civil unrest, and flooding. 

The LCES systems approach to fire line safety is an outgrowth of analysis of fatalities and near misses

for more than 20 years of active wildland firefighting operations. LCES simply focuses on the essential 

elements of the standard FIRE ORDERS (See Appendix Two). LCES should be automatic in 

wildland firefighting operations, and all fire fighters should know LCES. LCES functions sequentially 

- it's a self-triggering mechanism. Lookouts assess - and reassess - the fire environment and

communicate threats to safety to affected members; fire fighters use escape routes to safety zones. All

fire fighters should be alert to changes in the fire environment and have the authority to initiate

communication [NWCG 2018a].
Page 32 

One Fire Fighter Dies and One Fire Fighter Burned during 

Firefighting Operations at Grass Fire-Texas 

Report # F2018-07

To take the process a step further, situational awareness enhances the LCES system by being aware of

what is happening around you at an incident scene to understand how information, events, and your 

own actions will impact operational goals and incident objectives, both now and in the near future.

Situational Awareness becomes especially important in the firefighting operations and fire fighter

domains where the information flow can be quite high and poor decisions can lead to serious 

consequences [Naum 2011].

Situational awareness is a combination of attitudes, previously learned knowledge and new 

information gained from the incident scene and environment that enables the incident commander, 

tactical level managers, and company officers to gather the information they need to make effective

decisions that will keep their fire fighters and resources out of harm’s way, reducing the likelihood of 

adverse or detrimental effects [Naum 2011].

The key is that the lookout(s) must be qualified individual(s) that follow the checklist provided in the 

NWCG “Incident Response Pocket Guide” [NWCG 2018a]: 

• Experienced, competent, trusted;

• Enough lookouts at good vantage points;

• Knowledge of crew locations;

• Knowledge of escape and safety locations;

• Knowledge of trigger points;

• Equipped with a map, weather kit, watch, and Incident Action Plan [NWCG 2018a].

At this incident, there was no indication that lookouts, communications, escape routes, and safety 

zones (LCES) were established and communicated to all fire fighters.

Recommendation #8: Fire departments and fire service agencies should ensure that fire fighters 

fully comply with “The Ten Standard Fire Orders” and are aware of the “18 Watchout Situations” 

and “Common Denominators of Fire Behavior on Tragedy Fires” when fighting wildland fires. 

Discussion: Fire fighter and public safety is the first priority of the wildland fire management program.

To ensure wildland fire fighter safety, it is important to follow the Ten Standard Fire Orders, 

recognize the “Watchout Situations”, and recognize the “common denominators of fire behavior on 

tragedy fires” [NWCG 2018a]. Note: “The Ten Standard Fire Orders”, “18 Watchout Situations”, 

and “Common Denominators of Fire Behavior on Tragedy Fires” are listed in Appendix Two. 

The original Ten Standard Fire Orders were developed in 1957 by a task force commissioned 

by the United States Department of Agriculture’s Forest Service . The task force reviewed the records 

of 16 tragic fires that occurred from 1937 to 1956. The Ten Standard Fire Orders were based in part 

on the successful "General Orders" used by the United States Armed Forces. The Ten Standard Fire 

Orders are organized in a deliberate and sequential way to be implemented systematically and applied

to all fire situations.
Page 33 

One Fire Fighter Dies and One Fire Fighter Burned during 

Firefighting Operations at Grass Fire-Texas 

Report # F2018-07

Shortly after the Ten Standard Fire Orders were incorporated into fire fighter training, the 18 

Watchout Situations [NWCG 2018a] were developed. These 18 Watchout Situations are more specific 

and cautionary than the Ten Standard Firefighting Orders and describe situations that expand the ten

points of the Fire Orders. If fire fighters follow the Standard Fire Orders and are alerted to the 18 

Watchout Situations, much of the risk of firefighting can be reduced. 

In the mid-1970s, fire researcher Carl Wilson identified four common denominators of fire behavior 

that caused fatalities and near-misses on wildland fires. These four common denominators have been 

cited for decades in fire safety training, in the "Wildland Fire Incident Management Field Guide” 

(PMS 210) and in the "Incident Response Pocket Guide" (PMS # 461) [NWCG 2014, NWCG 2018a]. 

At this incident, there was no indication of compliance with “The Ten Standard Fire Orders” and an

awareness of the “18 Watchout Situations” and “Common Denominators of Fire Behavior on Tragedy 

Fires”.

Recommendation #9: Fire fighters who engage in wildland firefighting should be trained to meet 

the minimum training requirements as required by the National Wildfire Coordinating Group 

(NWCG) or NFPA 1051, Standard for Wildland Fire Fighter Professional Qualifications.

Discussion: Rural and volunteer fire fighters increasingly manage and provide firefighting operations 

for wildland fires. As previously mentioned, few fire fighters interviewed during this incident reported 

having participated in any formalized wildland firefighting training.

The National Wildfire Coordinating Group (NWCG) provides leadership specific to the wildland fire 

community regarding training, standards, equipment, firefighting qualifications, and other fire 

functions specific to wildland firefighting. From a training standpoint, the National Interagency 

Incident Management System Wildland Fire Qualification System Guide describes the minimal

qualifications and training recommended, and even required in some cases, when engaging in wildland 

fire operations [NWCG 2018b]. NWCG recommends the minimum training for fire fighters (NWCG 

Fire Fighter Type II) involved with wildland incidents should be I-100, Introduction to the Incident 

Command System, S-130, Fire Fighter Training, L-180, Human Factors on the Fireline, and S-190, 

Introduction to Wildland Fire Behavior [NWCG 2018b]. It is recommended that all rural and volunteer 

fire fighters, who engage grass and wildland fires, meet the NWCG minimal training requirements. 

These qualifications also meet the requirements of NFPA 1051, Standard for Wildland Fire Fighter 

Professional Qualifications, Wildland Fire Fighter I [NFPA 2016c]

Fire fighters, especially those trained in structural firefighting need to meet the requirements for 

wildland fire fighter training to ensure they have the necessary knowledge, skills, and competencies 

that ensure their safety during wildland urban interface fires. 

At this incident, there was no defined process for fire fighters to receive training within the department. 
Page 34 

One Fire Fighter Dies and One Fire Fighter Burned during 

Firefighting Operations at Grass Fire-Texas 

Report # F2018-07

Recommendation #10: Fire departments should develop, implement, and manage a comprehensive 

training program to ensure knowledge, skills, abilities, and competencies are maintained for

emergency response.

Discussion: Fire fighters encounter significant risks and hazards during emergency operations which

can lead to an occupational injury or even death. Fire fighters must be provided with the necessary 

knowledge, skills, and abilities to ensure that they can perform their job tasks safely and effectively. 

One of the most important risk management control measures used to prevent occupational injuries, 

illnesses, and fatalities is a viable training and certification program. Each fire fighter must be

properly trained to complete the necessary job functions and tasks they are expected to perform during 

emergency operations. As each state is different in the mandatory requirements for training and

certifying fire fighters, there should be a consistent model which requires that all fire fighters complete

at least NFPA 1001, Standard for Professional Qualifications for Fire Fighters, Fire Fighter I [NFPA 

2019]. 

The state of Texas does not have minimal qualifications for structural firefighting for volunteer fire 

fighters. Most fire departments in Texas do not have minimal requirements for wildland 

firefighting although 60% of their calls involve wildland firefighting operations. To ensure the safety 

of the fire fighters, the state should consider developing mandatory requirements that all fire fighters 

meet the training requirements as defined by NFPA 1001, Standard for Professional Qualifications for 

Fire Fighters, Fire Fighter I and the National Wildfire Coordinating Group and NFPA 1051, Standard 

on Wildland Fire Fighters Professional Qualifications, Wildland Fire Fighter I.

There was no defined process for fire fighters to receive training within the department.

Recommendation#11: Fire departments that operate Type V or Type VI Wildland Apparatus should 

have radio or intercom communications between the driver/operator and fire fighters.

Discussion: The safety of fire fighters riding on and operating around wildland fire apparatus (Type V 

and Type VI) is paramount. Fire fighters operating from the side step position on a wildland engine are 

exposed to the elements and surrounding noise. This includes the operation of the vehicle’s fire pump, 

apparatus engine and other equipment that may be operating. The driver/operators of the wildland 

engine are exposed to the same noise as well as noise of radio traffic. Communication between the fire

fighters and driver/operator is vital for safe operations of the apparatus as well as the safety of all 

members riding on the apparatus. 

Communications between other fire apparatus, the dispatcher, and the incident commander are 

impacted by the type of incident, location of the fire, terrain, and operation of equipment. The fire 

fighters can help direct the driver/operator as necessary, provide a warning if the fire is near the 

apparatus, and any other safety issues that need to be communicated [USFA 2016]. 
Page 35 

One Fire Fighter Dies and One Fire Fighter Burned during 

Firefighting Operations at Grass Fire-Texas 

Report # F2018-07

Fire departments should acquire the necessary radio or intercom equipment to provide proper 

communications between the driver/operator of the apparatus and the fire fighters operating on the side 

step. There are a variety of commercially available products. 

Fire Station 5 Update

Since the incident on March 10, 2018 which resulted in a fire fighter fatality, Fire Station 5 has 

implemented several changes: 

• All members must wear wildland PPE when responding to wildland fires. If wildland PPE is

unavailable the member must wear structural turnout gear.

• The department is meeting two times each month. One meeting is composed of a business

meeting followed by training. The second meeting is composed solely of training. Training

attendance and the subject matter is documented and based on the State Firefighters’ and State

Fire Marshals’ Association of Texas curriculum or is EMS based.

• A complete set of Standard Operating Procedures and Standard Operating Guidelines are being

developed for all fire department operations

References 

Blue Card [2018]. Blue card command sops. BShifter; Phoenix, AZ 

http://www.bshifter.com/about_01.aspx 

Brunacini AV [2002]. Fire command. Quincy, MA: National Fire Protection Association. 

Chadwick, J [2014]. Fire Engineering, Risk Management: It's Not Just a Catchphrase. 

http://www.fireengineering.com/articles/print/volume-167/issue-8/features/risk-management-it-s-notjust-a-catchphrase-p1.html. Date accessed. November 18, 2018. 

Fire and Rescue Departments of Northern Virginia [2013]. Engine company operations. Fire and 

Rescue Departments of Northern Virginia, Firefighting and emergency operations manual. 2nd ed. 

Fairfax County, VA: Fire and Rescue Departments of Northern Virginia. 

FIRESCOPE [2015]. Incident command system for structure fire operations, ICS 500. Riverside, CA; 

FIRESCOPE. http://firescope.org/. 

NFPA [2012]. NFPA 1906, Standard for wildland fire apparatus. Quincy, MA: National Fire 

Protection Association. 

NFPA [2014]. NFPA 1561, Standard on emergency services incident management system and 

command safety. Quincy, MA: National Fire Protection Association. 

NFPA [2016a]. NFPA1977, Standard on protective clothing and equipment for wildland fire fighting. 

Quincy, MA: National Fire Protection Association.
Page 36 

One Fire Fighter Dies and One Fire Fighter Burned during 

Firefighting Operations at Grass Fire-Texas 

Report # F2018-07

NFPA [2016b]. NFPA 1906, Standard for wildland fire apparatus. Quincy, MA: National Fire 

Protection Association. 

NFPA [2016c]. NFPA 1051, Standard for wildland fire fighter professional qualifications. Quincy, 

MA: National Fire Protection Association.

NFPA [2018]. NFPA 1500, Standard on fire department occupational safety, health, and wellness 

program. Quincy, MA: National Fire Protection Association. 

NFPA [2019]. NFPA 1001, Standard for professional qualifications for fire fighters. Quincy, MA. 

National Fire Protection Association.

NWCG. [2014]. Wildland Fire Incident Management Field Guide. PMS 210 (NFES 002943). Boise, 

ID: National Wildfire Coordinating Group. 

https://www.nwcg.gov/sites/default/files/publications/pms210.pdf. 

NWCG [2018a] Incident Response Pocket Guide” (NWCG PMS #461). Boise, ID: National Wildfire 

Coordinating Group. https://www.nwcg.gov/sites/default/files/publications/pms461.pdf.

NWCG [2018b]. National interagency incident management system wildfire fire qualification system 

guide. Boise, ID: National Wildfire Coordinating Group. 

https://www.nwcg.gov/sites/default/files/publications/pms310-1.pdf.

Naum, C. [2011]. Situational Awareness and Risk Assessment. 

http://thecompanyofficer.com/2010/02/12/situational-awareness-and-risk-assessment/. Date accessed: 

November 18, 2018. 

Texas A&M University [2001]. Little Bluestem Grass. Dr. William C. Welch, Professor and Extension 

Horticulturist, Texas Cooperative Extension, Texas A&M System https://aggiehorticulture.tamu.edu/newsletters/hortupdate/hortupdate_archives/2001/sep01/art1sep.html. 

USFA [2016]. Voice Radio Communications Guide for the Fire Service. United States Fire 

Administration, Emmittsburg, MD. 

https://www.usfa.fema.gov/downloads/pdf/publications/voice_radio_communications_guide_for_the_f

ire_service.pdf. 
Page 37 

One Fire Fighter Dies and One Fire Fighter Burned during 

Firefighting Operations at Grass Fire-Texas 

Report # F2018-07

Weather Underground. Weather history for K3T5, Saturday, March 10, 2018, Atlanta, GA: The Weather 

Channel Interactive, Inc.,

https://www.wunderground.com/history/airport/K3T5/2018/3/10/DailyHistory.html?req_city=Ellinger

&req_state=TX&req_statename=Texas&reqdb.zip=78938&reqdb.magic=1&reqdb.wmo=99999&hdf=

1.

Investigator Information

This incident was investigated by Murrey E. Loflin, Investigator, with the Fire Fighter Fatality 

Investigation and Prevention Program, Surveillance and Field Investigations Branch, Division of 

Safety Research, NIOSH located in Morgantown, West Virginia. An expert technical review was 

provided by Scott D. Kerwood, Fire Chief of Hutto, TX Fire Rescue. A technical review was also 

provided by the National Fire Protection Association, Public Fire Protection Division. 

Additional Information

The Texas State Fire Marshal’s Office conducted a separate investigation of this incident. Their 

investigation report will be available at http://www.tdi.state.tx.us/fire/fmloddinvesti.html. 

Disclaimer 

Mention of any company or product does not constitute endorsement by the National Institute for 

Occupational Safety and Health (NIOSH). In addition, citations to websites external to NIOSH do not 

constitute NIOSH endorsement of the sponsoring organizations or their programs or products. 

Furthermore, NIOSH is not responsible for the content of these websites. All web addresses referenced 

in this document were accessible as of the publication date. 
Page 38 

One Fire Fighter Dies and One Fire Fighter Burned during 

Firefighting Operations at Grass Fire-Texas 

Report # F2018-07

Appendix One

Lookouts, Communications, Escape Routes, and Safety Zones (LCES)

LOOKOUT

• Experienced / Competent / Trusted

• Enough lookouts at good vantage points

• Knowledge of crew locations

• Knowledge of escape and safety locations

• Knowledge of trigger points

• Map / Weather Kit / Watch / IAP

COMMUNICATIONS

• Radio frequencies confirmed

• Backup procedures and check-in times established

• Provide updates on any situation change

• Sound alarm early, not late

ESCAPE ROUTES

• More than one escape route

• Avoid steep uphill escape routes

• Scouted: Loose soils / Rocks / Vegetation

• Timed: Slowest person / Fatigue & Temperature • Marked: Flagged for day or night

• Evaluate: Escape time vs. Rate of spread

• Vehicles parked for escape

SAFETY ZONES

• Survivable without a fire shelter

• Back into clean burn

• Natural Features: Rock Areas / Water / Meadows

• Constructed Sites: Clearcuts / Roads / Helispots

• Scouted for size and hazards

• Upslope?

• Downwind? More heat impact Larger Safety Zone

• Heavy Fuels?

NOTE: Escape time and safety zone size requirements will change as fire behavior changes. More 

heat impact LARGER safety zone 
Page 39 

One Fire Fighter Dies and One Fire Fighter Burned during 

Firefighting Operations at Grass Fire-Texas 

Report # F2018-07

Appendix Two

“The Ten Standard Fire Orders” “18 Watchout Situations” and

“Common Denominators of Fire Behavior on Tragedy Fires.”

The Ten Standard FIRE ORDERS are:

1. Keep informed on fire weather conditions and forecasts.

2. Know what your fire is doing at all times.

3. Base all actions on current and expected behavior of the fire.

4. Identify escape routes and safety zones and make them known.

5. Post lookouts when there is possible danger.

6. Be alert. Keep calm. Think clearly. Act decisively.

7. Maintain prompt communications with your forces, your supervisor, and adjoining forces.

8. Give clear instructions and insure they are understood.

9. Maintain control of your forces at all times.

10. Fight fire aggressively, having provided for safety first.

The 18 Watchout Situations are:

1. Fire not scouted and sized up.

2. In country not seen in daylight.

3. Safety zones and escape routes not identified.

4. Unfamiliar with weather and local factors influencing fire behavior.

5. Uninformed on strategy, tactics, and hazards.

6. Instructions and assignments not clear.

7. No communication link with crewmembers/supervisors.

8. Constructing line without safe anchor point.

9. Building fireline downhill with fire below.

10. Attempting frontal assault on fire.

11. Unburned fuel between you and the fire.

12. Cannot see main fire, not in contact with anyone who can.

13. On a hillside where rolling material can ignite fuel below.

14. Weather is getting hotter and drier.

15. Wind increases and/or changes direction.

16. Getting frequent spot fires across line.

17. Terrain and fuels make escape to safety zones difficult.

18. Taking a nap near the fire line.

There are four major common denominators of fire behavior on fatal and near-fatal fires. Such fires

often occur:

1. On relatively small fires or deceptively quiet areas of large fires.

2. In relatively light fuels, such as grass, herbs, and light brush.

3. When there is an unexpected shift in wind direction or wind speed.
Page 40 

One Fire Fighter Dies and One Fire Fighter Burned during 

Firefighting Operations at Grass Fire-Texas 

Report # F2018-07

4. When fire responds to topographic conditions and runs uphill.

Alignment of topography and wind during the burning period should always be considered a 

trigger point to re-evaluate strategy and tactics.