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Beyond the report: How chiefs can drive cultural change after an investigation

From Los Angeles to Baltimore, and Pennsylvania most recently, we must consider how we use the lessons learned from significant incidents


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In recent weeks, we’ve seen the release of the National Fallen Firefighters Foundation (NFFF) documentary “Boyd Street” about the 2020 blast that injured 11 LAFD firefighters, plus the release of the Baltimore Board of Inquiry investigation report into the Stricker Street fire in which three city firefighters were killed.

The documentary and LODD report are consistent with other significant-incident analysis that detail a wide array of harrowing actions and potential lessons learned. I say “potential” because they’re only lessons learned if they change the culture that allowed the problems in the first place. Only time will tell whether they’re truly lessons learned as opposed to simply lessons reported.

And as we are still processing the reflections from the Los Angeles and Baltimore incidents, last week, two Pennsylvania firefighters died at a house fire where civilians were reported as trapped. No civilians were ultimately found inside the home. The firefighters died during search operations more than 45 minutes after firefighters arrived on the scene. (A civilian was later found deceased in the rear yard, an apparent death by suicide.)


The Baltimore Board of Inquiry investigation report into the Stricker Street fire in which three city firefighters were killed has been released.

While the Pennsylvania incident is too new for a report to have even been initiated, there will undoubtedly be meaningful findings to emerge for the fire service – there always are. The big question is whether the rest of us ever hear about such findings.

Commonalities within culture

I have listened to the audio from Pennsylvania, and I’ve watched the Los Angeles video and read the Baltimore report. In all three of these incidents, there are critical lessons that can guide us toward systemic improvement.

Note: It is a delicate tight rope to walk when we analyze these incidents, as most of us simply were not there. This analysis is in no way intended to criticize the firefighters. Each of these departments responded with honor to their incidents. The goal here is to address common themes and share the lessons to avoid such tragedies in the future.

Specifically, while the incident outcomes were significantly different among these three incidents, there are striking similarities related to department culture that saturates many of our big-city and smaller departments alike. We can hear the impact of culture in their own words:

  • Los Angeles: The firefighters saying honestly that wearing masks while on the roof “just wasn’t what we did,” coupled with the visual display of numerous SCBA waist straps dangling below firefighters’ waists.
  • Baltimore: In reading the Baltimore report where the incident commander acknowledged that no form of command worksheet, software or accountability was in use.
  • Pennsylvania: In the audio, the only on-scene report given (by a chief officer) was, “on the scene with heavy smoke showing.”

Do you see the common culture-rooted issues here?

Transparency with significant incidents

While the emergency nature of what we do necessitates that we act in the OODA loop environment (observe, orient, decide and act), the non-emergent after-action reviews and other investigations do not; we can take our time to process what we know. However, simply conducting a safety investigation should not be the end of the life cycle for a significant event.

Such reports can be critical for individual departments, but we tend to lose focus on root cause and effect when we read these reports one at a time, removed from the context of other, similar events. If there is ever to be real change, there must be a broader analysis that considers how the event fits into the larger context of fire service culture.

Further, understanding that there will likely be legal issues to consider with such reports, we as a business will never learn from our mistakes if we always hide behind legal counsel. Chiefs must try to find the balance between respecting legal guidance and sharing any helpful lessons from our darkest days on the job. In my opinion, not releasing the report should never be the go-to option.

So, how do we improve our transparency related to these reports? We must have the courage to do the right things, over and over again.

One example: In 2012, as fire chief of the Prince George’s County (Maryland) Fire/EMS Department, I took steps with the 2012 57th Avenue Safety Investigation Team (SIT) report to address many of the cultural impediments to improvement. The key to breaking that cycle was the comparison of that report’s recommendations to other, similar safety investigation report recommendations. The results were, frankly, shocking: 20 of the 46 recommendations were also recommendations from previous SIT reports, as far back as 23 years prior, including one LODD fire.

Similarly, the 2022 Baltimore report included a comparison of previous report recommendations, finding 16 of their recommendations were also recommendations from previous reports. As we did immediately in Prince George’s County, Baltimore has begun the process of improvement implementation. THAT is how we begin to break the culture of complacency.

We can’t ‘kick the can down the road’

Let’s consider another example of how a department handled an incident analysis and was transparent about its past shortcomings in order to implement positive change.

In 2015, the Fresno (California) Fire Department experienced a close call when Captain Pete Dern fell through the roof of a single-story single-family home. Captain Dern received third-degree burns over 70% of his body and was likely seconds from death before being pulled out by fellow firefighters. Dern has not been able to return to duty, but he talks about the incident today, focusing on resilience and perseverance.

Fresno’s report identified the No. 1 factor in need of change as the departments “culture of safety.” This quote from Fresno Fire Chief Kerri Donis captures the essence of most, if not all, of the other jurisdictional reports I’ve read:

These are some of the practices and things that have been occurring in this organization for years and years and years. This isn’t something that has just occurred in the last year or since Captain Dern’s incident. We essentially have kind of kicked the can down the road in this department and in other departments and have not really poured a lot of commitment to making cultural change and to change our firefighting practices.”

Fresno went about the business of making positive change to improve firefighter safety, while still providing guidance for an aggressive firefighting force. For example, significant changes to roof policies and command and control functionalities were some of the primary areas of focus in the Fresno report.

The life cycle of significant event analysis

From Maryland and California and everywhere in between, progress improvement simply cannot stop when the report is completed.

Here’s what I see as the life cycle of any safety investigation report:

  • Event occurs
  • Safety investigation conducted (NOT a disciplinary investigation), with input from:
    • Internal SMEs (Operations, training, administration, union – and/or volunteer)
    • External FD SMEs
    • Industry SMEs
    • Administrative assistants
  • Investigation conducted, including the following:
    • Interviews and scene analysis
    • Statements of fact
    • Comparison of previous report recommendations
    • Improvement recommendations
      • Prioritization
      • Fiscal analysis
      • Training plan
      • Ongoing evaluation plan
  • Report submitted
  • Recommendations evaluated
  • Budget and training needs determined and secured
  • Implementation planned
  • Implementation begun
  • Report released

Getting the report done is great – but now what?

After any report with significant findings and recommendations, chiefs should assemble an Implementation Task Force” (team, committee, workgroup), comprised of many individuals – individuals who were not on the safety investigation team. The team should be tasked with the following:

  • Recommending strategies for fiscal acquisition needs (e.g., grant applications vs. local government appropriations and budget reprogramming);
  • Creating a reasonable timeline for recommendation implementation;
  • Determining the most timely and efficient method for training delivery, all the way down to the firehouse level (this might involve existing online learning management platforms, new in-service live-training modules, or reference to existing and refreshed program reviews); and
  • Identifying key supportive internal and external stakeholders. Some recommendations may impact other entities and/or organizations, requiring collaborative training approaches (e.g., active shooter or traffic incident management training).

Many recommendations from these reviews will be worked into existing mechanisms for communication to and training the troops. You must ensure that the entire command staff has ownership and is held accountable to deliver change-messaging in a method beyond “because the chief said.”

After the implementation program is rolling, recommendations should be reviewed annually (or at whatever interval works for your organization) by your organization’s safety and training offices and/or committees. This process is where the concepts of the OODA loop or the “Planning P” can come into practice.

I followed this path in Prince George’s County with an implementation task force of stakeholders separate from the safety investigation team. After the implementation team gave me their plan, it was all on me as the chief from a policy and expectation perspective. A standing work group for policy development assisted with the development of necessary orders and protocols.

I fully recognize that reports will likely be released before significant improvement strategies have been approved or possibly before any significant improvement has occurred. Some recommendations may carry millions of dollars in costs and take years to implement. Mind you, some other recommendations that don’t have true costs associated will be easier to implement than more costly recommendations. Establish a plan and get moving!

Chiefs, lead the way

Regardless of the timing, it’s up to us to not repeat the mistakes of the past – and to stop kicking the can down the road. We are only going to get there by doing the right thing, now – not later, NOW. There will likely be things that some of the troops don’t like. There will likely have to be a significant “sell” to achieve member buy-in, especially for some of the most tenured members within your organization. Some will forever fight any kind of change, but the effort is not only important, it’s essential to the future of your organization.

Organizational-level cultural change and recovery from significant incidents is where we need much more leadership than friendship. Remember, leadership in its truest sense is about taking people and organizations where they need to be, which may not be where they want to be.

Chief Marc S. Bashoor joined the Lexipol team in 2018, serving as the FireRescue1 and Fire Chief executive editor and a member of the Editorial Advisory Board. With 40 years in emergency services, Chief Bashoor previously served as public safety director in Highlands County, Florida; as chief of the Prince George’s County (Maryland) Fire/EMS Department; and as emergency manager in Mineral County, West Virginia. Chief Bashoor assisted the NFPA with fire service missions in Brazil and China, and has presented at many industry conferences and trade shows. He has contributed to several industry publications. He is a National Pro-board certified Fire Officer IV, Fire Instructor III and Fire Instructor. Connect with Chief Bashoor at on Twitter, Facebook or LinkedIn. Do you have a leadership tip or incident you’d like to discuss? Send the chief an email.