Intent

Review the sequence of events that led to the Golden Gate Estates Fire tragedy and discuss significant lessons learned.

Facilitator Preparation

• Review the video, module tools, and additional resources linked below.
• Consider additional activities and discussion questions pertinent to your location and agency.
• Guide discussion based on the Risk Management Process in the Incident Response Pocket Guide (IRPG), PMS 461. Provide copies of the IRPG for students to utilize and answer questions.
• Guide discussion based on Working with Heavy Equipment in the Incident Response Pocket Guide (IRPG), PMS 461. Provide copies of the IRPG for students to utilize and answer questions.

Facilitating the Discussion

• Show the video.
• Facilitate a discussion using the Discussion Questions below.
• (Optional) Conduct additional activities pertinent to your location.
• Discuss group responses.

Discussion Questions

Part 1

Identify Hazards (Situation Awareness)

1. When did the involved personnel obtain the basic critical information?
   1. Objectives, communication, who’s in charge, previous fire behavior, weather forecast, and local factors.
   2. Was the assignment scouted?

Assess Hazards

1. Were potential fire behavior hazards estimated?
2. Which tactical hazards or Watch Out Situations were present?
3. What other warnings or indicators were present prior to the entrapment?

Develop Controls and Make Risk Decisions

1. Where was the fireline anchor point?
2. Was there an established lookout?
3. What communication links were in place between the involved personnel and their fireline supervisor or adjoining forces?
4. What was the pre-identified escape route(s)?
5. What was the pre-identified safety zone(s)?
6. Was a Medical Plan in place?

Implement Controls

1. Were the necessary hazard controls in place for this situation? If not, what was lacking?
2. Were the strategies and tactics based on expected fire behavior? If not, why?
3. Did all involved resources have an opportunity for feedback during the decision-making process? If not, why?

Supervise and Evaluate

1. What individual or human factors existed that increased the potential for decision errors?
2. What organizational factors existed that increased the potential for decision errors?
3. As the fire and situation evolved, did the strategy, and tactics continue to work? Did the hazard controls evolve as the fire and situation evolved?

Part 2

• Consider the causal factors identified in Part 1; then summarize the significant lessons to be learned from this case study.

Resources

• Document: Golden Gate Estates Fire Fatality Accident Report
• Publication: Incident Response Pocket Guide (IRPG), PMS 461

Additional Video Information

• The video is also available as a download (zip file, size 965 MB) with .srt file for closed captioning (you may need to right click and Save As). For information on how to add closed captioning to a video, see this how to page.
• Note: For Chrome, Firefox, and Edge, right click the word download and select Save Link As; for IE, right click and select Save Target As.