Serious Incident Review support helps fire departments understand how and why serious firefighter injuries or line-of-duty deaths occurred. Command Competence provides detailed operational analysis focused on fire behavior, decision making, command processes, and organizational factors to support learning and improvement.
The purpose of a Serious Incident Review is to develop actionable lessons that can improve training, tactics, command performance, and organizational systems. Our approach emphasizes operational learning and organizational improvement rather than fault assignment or legal advocacy.
Why Serious Incident Review Matters
Serious firefighter injuries and line-of-duty deaths are rare, high-impact events that can expose complex interactions among fire behavior, tactical decision making, incident command, and organizational systems.
A structured operational review helps fire departments understand these interactions, identify decision and system factors that contributed to the outcome, and translate findings into improvements in training, tactics, procedures, and command performance.
Our focus is actionable learning and system improvement, not assignment of fault.
What We Do
Serious Incident Review consulting may include:
Incident Timeline Reconstruction
We reconstruct the incident timeline using available data, interviews, communications, video, and documentation to establish a factual baseline of conditions, cues, actions, decisions, and outcomes.
Operational Decision and Command Analysis
We analyze decision making, sensemaking, and command actions to understand how firefighters and officers interpreted available information, anticipated incident development, made decisions, and acted during the incident.
Fire Behavior Interpretation
We examine fire development, ventilation, flow paths, compartment conditions, and other relevant fire dynamics to provide the technical context necessary to understand operational conditions and tactical decisions.
Organizational and System Factors
We consider organizational factors that may have influenced operational performance, including training systems, supervision, communication practices, procedures, and pre-incident planning.
Findings and Recommendations
We develop written findings and actionable recommendations focused on training and system improvement and tailored to the department’s operational context.
How We Work
The Serious Incident Review process is tailored to the incident and the needs of the organization. A review typically includes:
- Initial scoping and data collection
- Review of incident documentation, communications, photographs, and video
- Interviews with firefighters, officers, and other key participants
- Reconstruction of the incident timeline
- Structured analysis of fire behavior, decision making, command, and organizational factors
- Development of findings and recommendations
- Delivery of a written report and leadership debrief
Throughout the process, we use clear, non-judgmental language and maintain a focus on learning and organizational improvement.
Typical Use Cases
Serious Incident Review support may be appropriate for:
- Line-of-duty death investigations
- Serious firefighter injury reviews
- Near-miss investigations involving significant potential consequences
- Organizational learning and training improvement
- Assessment of system factors contributing to operational outcomes
- Leadership and command development following critical incidents
Deliverables
Depending on the scope of the review, deliverables may include:
- Detailed incident timeline
- Operational decision and command analysis
- Fire behavior analysis and interpretation
- Analysis of organizational and system factors
- Recommendations for training, systems, procedures, and operational practice
- Executive summary
- Leadership presentation or slide deck
Outcomes
A Serious Incident Review provides the organization with a clearer understanding of what happened, how the incident developed, and why actions and decisions made sense within the conditions confronting firefighters and officers at the time.
The review translates that understanding into actionable opportunities to improve training, tactics, command performance, procedures, and organizational systems.
Prior Work
Command Competence provides support across a range of serious injury and line-of-duty death review activities, including independent technical analysis, advisory support to internal investigation teams, and contribution to multi-agency review processes.
In 2024, Chief Ed Hartin provided technical and operational analysis support for a serious firefighter injury investigation involving a residential fire flashover. This included development of the incident timeline, video and fire behavior analysis, interviews with the firefighters and officers involved, and assistance in developing recommendations. The final report is available here:
Gresham Fire Department Serious Incident Review May 30, 2024
In 2026, Chief Ed Hartin investigated a near miss that occurred during live fire training. While this incident resulted in a minor injury, the potential consequences could have been much worse. This investigation included development of a timeline, fire behavior analysis, interviews with the firefighters and officers involved, and development of recommendations.
East County Fire and Rescue Near Miss Investigation Report July 1, 2026
Chief Ed Hartin has also served as an expert technical reviewer for multiple NIOSH Fire Fighter Fatality Investigation and Prevention Program reports, providing independent review of fire behavior interpretation, operational decision making, and command processes.
Related Services
These services build on or complement Serious Incident Review:
- Fireground Decision-Making & Incident Command Consulting — cognitive and operational performance improvement
- Simulation and Scenario Development — scenario-based practice developed from operational needs and review findings
- Fire Dynamics Training — development of the fire behavior knowledge needed to support tactical decision making
Get Started
Serious incidents demand thoughtful analysis grounded in the operational context in which firefighters and officers made decisions.
Contact Command Competence to discuss Serious Incident Review support and how structured operational analysis can help your department translate a difficult event into meaningful improvements in training, tactics, command performance, and organizational systems.