Will the fire community benefit from the ‘lessons learned’ concept and sustain a ‘safety culture’ wh
Will the fire community benefit from the ‘lessons learned’ concept and sustain a ‘safety culture’ when all the wildfire fatality investigations/reports are based on predetermined conclusions?
2018-07-14 | Arizona Desert Walker Joy A. Collura and contributing other(s)
Views expressed to "the public at large” and "of public concern"
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The various Firefighter groups that I have become aware of are many. They include the many structure/municipal/wildland fire departments from the big cities to the small, full-time and part-time Volunteer FDs, referred to by some as “hybrids.” These folks fight conventional structure fires; information, education, and prevention tasks; perform various medical functions, technical rescue work, and more, and then wildland fires. Many of the California city, county, and State (I still call them CDF, i.e. CALFire) FD’ are well versed in wildland fire. Then there are the specialized wildland firefighters that are focused on just that specific area. And those are categorized into Engine Crews, Hand Crews, Type 1 Hot Shot Crews, Smokejumpers, Helitack and Heli-rappeler Crews, Type 2IA Crews, Type 2 Crews, and Dozer and/or Tractor Plow Crews.
The largest stakeholders are obviously the Federal Government agencies, (e.g. USFS, BLM, BIA, USFWS), then next would likely be the State and County Fire Management agencies, followed by the local Government agencies. And then there are the private contractors and they run the gamut from really good to really poor or worse. It seems as if the Government has imposed a competition / restriction among the contractors and local Government resources.
All of these WFs are required to be trained and qualified to fight fire and carry a Red Card, that is actually white, denoting that they have passed muster within their Agency or sponsor in order to fight fire.
After the tragic 1994 South Canyon Fire in Colorado where fourteen WFs perished the federal Agencies authorized the “Wildland Firefighter Safety Awareness Study - TriData Reports” (1996)
Summarizing the beginning of a new WF safety culture: “… After this devastating tragedy, a consensus emerged in the wildland fire community. Despite a great deal of attention to safety, the same unsolved problems and underlying factors were reoccurring and, unfortunately, adding to an already long legacy of tragedy fires. Following powerful soul-searching, multiple agency investigations, and special conferences on safety in response to the South Canyon Fire, a new idea arose. It became clear that the usual causal factors sought in fatality fire investigations were not achieving their objectives for change. Therefore, the five federal wildland firefighting agencies decided to pool their support for an examination of the wildland firefighter safety problem in greater depth. In 1994-1995, an interagency committee met to formulate what became the concept for this study. From the outset, the study’s intent was very clear: to contribute to a reduction in fatalities and injuries associated with wildland firefighting. … This landmark wildland firefighter safety awareness study, known as “TriData” after the safety consulting firm’s name that was hired to conduct this major undertaking, was dedicated to the more than 1,000 federal and state wildland firefighters who contributed their time and heartfelt thoughts to this significant project. (Ramona Beyuka – WFLLC - June 26, 2016)” (emphasis added)
Dr. Ted Putnam, who refused to sign the 1994 South Canyon Fire Investigation Report because it was a cover-up and sham, later had a paper published by the influential International Association of Wildland Fire (IAWF) titled “Accident, Accident Guides, Stories, and Truth” at the Eleventh International Wildland Fire Safety Summit in April 2011 at the Hilton Garden Inn Missoula, MT. The theme was Promoting the Story of Wildland Fire Safety. Dr. Putnam's paper finally exists online here, Academia.edu, and now the WLF LLC.
The Wildland Fire Lessons Learned Center (WFLLC) FINALLY posted it (albeit hidden) on their Federally funded website to comply with their published Mission and Vision Statements. See Academia.edu link below.
The WFLLC Mission Statement: 'Our Mission is to promote learning in the wildland fire service by providing useful and relevant products that help to reveal the complexity and risk in the wildland fire environment.' I think you’ll agree that’s pretty specific and binding. The following is a link from InvestigativeMedia (IM) regarding the previously biased WFLLC procedure for approved submissions for lessons learned:
( http://www.investigativemedia.com/please-begin-yarnell-hill-fire-chapter-xxvi-here/#comment-474633 )
This is an email Snippet below in Figure 1 from the WLF LLC to Fred Schoeffler, acknowledging their posting of Dr. Putnam's IAWF research paper (2011) titled: Accidents, Accident Guides, Stories, and Truth." FINALLY!
Figure 1. Snippet of WLF LLC email thread acknowledging Putnam posting. Source: Gmail
It can be found here ( https://www.wildfirelessons.net/viewdocument/accidents-accident-guides-stories ) on the WLF LLC website.
Dr. Putnam’s published paper dealing with the overall wildland fire management’s mishandling of all of the Serious Accident Investigations and Reports have a recurring pattern of lies and cover-ups and whitewashes. Surely, these would align squarely within the realm defined in their WFLLC Mission Statement.
Dr. Putnam wrote: about the 1949 Mann Gulch Fire: "My summary points are that Mann Gulch was an elaborate cover-up from the start, did little to help future firefighters and mostly protected upper level managers and the Agency’s images. I invite readers to go back and take a more thorough look at the available evidence and to realize, like I have, that the Mann Gulch investigation set the pattern for later fatality investigations, namely that it is ok to cover-up the truth and blame firefighters and fire behavior than mental errors, cultures, managers or organizations. If our accident investigations don't promote finding and telling the Truth then Lessons Learned, firefighter safety and High Reliability Organizations are just convenient buzz words; lullabies numbing us out rather than keeping us awake to underlying conditions and causal elements which best account for our collective firefighter realities." (emphasis added)
Here is Dr. Putnam's comments about the 1994 South Canyon Fire: "Many causal factors for the deaths at South Canyon were never mentioned in the official report. ... I did not sign the report mostly due to it being poorly written as stated above. Too many errors were present which would lead readers into false conclusions; likely by design to shift blame away from BLM managers onto the dead firefighters. I had marked up three pages that were more of what most people would consider “editorial” in nature. The causal factors being covered up were not part of refusing to sign the report because our team leaders told us that the report being printed for “public analysis” was the best we could do in the allotted 45 days. Team leaders assured other team members that the final report would include all the casual factors after we better understood them by continued analysis. Historically I do not know if this was an up-front lie or if the decision to axe the final report came later. Thus the South Canyon report has elements of deliberate cover-ups like Mann Gulch and elements of partial cover-ups, with the promise that another report is coming and “trust us to fix the problems later.” No later team report was written. Had I known that no further report was going to come out then the primary reason for not signing the report would have been the failure to report all the prime causal factors for the fourteen deaths." (emphasis added)
Indeed, a published paper in the highly recognized IAWF should, by all rights, be published on the WFLLC website based solely on their all-encompassing Mission Statement.
Their Mission Statement requires it: “… promote learning in the wildland fire service by providing useful and relevant products that help to reveal the complexity and risk in the wildland fire environment.” (emphasis added) I would think that exposing the lies and cover-ups of fatality and fire entrapment fires going all the way back to the 1949 Mann Gulch Fire (MT) where thirteen WFS died, would be mandatory for the WFLLC.
And then came the June 30, 2013, Yarnell Hill Fire (YH Fire) where 19 Prescott FD Granite Mountain Hot Shots (GMHS) perished. Two Arizona State investigations were ordered by the AZ State Forestry Department (ASF): one a Serious Accident Investigation Team (SAIT) to prepare a Serious Accident Investigation Report (SAIR) and a separate Arizona Division of Occupational Safety and Health (ADOSH) Investigation far exceeded the Mann Gulch Board of Review findings.
Conventional logic stipulates that first facts are discovered which then lead the fact-finder to a conclusion(s). This is NOT the case for wildland fire fatality and burnover, fire shelter deployment investigations. The current trend in wildland fire fatality reports and/or reviews is that the “conclusion” seems to be almost always predetermined and then the “facts” are discovered to support the foregone conclusion. Some WFs who have experienced and/or participated in these SAITs go so far as to say that the conclusion is determined once the team leader is chosen.
In Dr. Putnam ‘s “Accident, Accident Guides, Stories, and Truth” paper he outlines the faults of the various accident guides and protocols and what is needed to correct those shortcomings and how to properly perform an honest and truthful investigation.
Predictably, YH Fire SAIT-SAIR concluded: “The judgments and decisions of the incident management organizations managing this fire were reasonable. Firefighters performed within their scope of duty, as defined by their respective organizations. The Team found no indication of negligence, reckless actions, or violations of policy or protocol.” (emphasis added) (SAIT-SAIR pp. 3-4)
This is a classic case of establish a conclusion first then find the facts. The SAIT-SAIR conclusion stated in the negative, so placing it into a positive statement means that they did everything right. How is it possible to do everything correctly and the IMT struggled to perform cohesively and efficiently, consistently underestimated Rates of Spread, overestimated their competency, and that nineteen WFs were killed in one-fell-swoop?
It is a conventional belief and wisdom among most WFs that the SAIT and Fatality Fire process is a sham and cannot be trusted or relied upon. So, the shifted sense of reality among these experienced WFs is to follow their own instincts, do your own thing, and to draw your own conclusions from the “facts” and “conclusions” presented in the SAIT-SAIRs because they cannot trust them.
Dr. Putnam once said something to the effect of ‘many of the serious accident and fatality fire investigations are partial lies and then we base the subsequent Staff Rides on these investigation reports, so all we are doing is promoting the lies as truth and so we get no true lessons learned from them. When lies are told and conveyed and they are never changed.’ We are not aware of any cases or evidence in the history of SAIT-SAIRs and Staff Rides when new evidence is found to prove certain segments of the SAIT-SAIRs as false. So then, neither the SAIT-SAIRs nor the Staff Rides are ever corrected. It would be an easy thing to do, to state that "new evidence has come to light" and we need to change this in the SAIT-SAIR and Staff Rides accordingly.
Here is an example of what the National Interagency Fire Center (NIFC) has stooped to a new low in order to train our WFs on the Ten Standard Fire orders and the Eighteen Watch Out Situations. It is rather nauseating. Or as many of the Congress, Arizona grade school children more accurately labeled it is “juvenile.” So then, NIFC, take a hint from some nine year olds, please spare us from anymore of these feculent, moronic attempts at this type of "new training" material currently being used in the system:
Therefore, the YH Fire SAIT-SAIR is likely the inevitable outcome of failing to follow Dr. Putnam’s keen advice on investigations and has become the new standard. But there is more to the story. “They” have designed even more ways to skew and conceal the truth.
One is the Coordinated Response Protocol (CRP) and Learning Review for serious accidents link. I call it CRaP for what it entails.
( https://www.fs.fed.us/rmrs/science-spotlights/coordinated-response-protocol-and-learning-review-serious-accidents )
You can also go to the Wildfire Today (WFT) article.
( http://wildfiretoday.com/wp-content/uploads/2014/08/WP-Coordinated-Response-Protocol-Paper.001.pdf ) and the official Coordinated Response Protocol Guide version ( https://www.fs.fed.us/rmrs/science-spotlights/coordinated-response-protocol-and-learning-review-serious-accidents ) (2017).
The CRaP concept was originated by Ivan Pupulidy, PhD, currently the Director of the U.S. Forest Service, Office of Innovation and Organizational Learning (IOL). He did his doctoral thesis on the subject, so he basically created his own job. Below is a Taos Institute, “Creating Promising Futures Through Social Construction” article about him and his accomplishments. ( https://www.taosinstitute.net/ivan-pupulidy )
Surprisingly, US Forestry employee and ‘Safety Researcher’ Dr. Ivan Pupulidy ( who is the author of the ‘new’ USFS ‘Accident Investigation Protocol’ that REPLACES the former “Special Accident Investigation Protocol” that was used to investigate the Yarnell tragedy ) recently called for an END to all the SECRECY that USFS and other State Forestry agencies normally use to ‘cover up’ what actually happened when there is any kind of ‘accident’.
Wildfire Today “USFS to use NEW ‘Serious Accident Review system” Published: August 7, 2014 – By Bill Gabbert ( http://wildfiretoday.com/2014/08/07/usfs-to-use-new-serious-accident-review-system/ )
“Ivan Pupulidy called us to say that he was the author of the new protocol. Presently he is the Acting Program Manager for Human Factors Risk Management Research Development and Application for the USFS’ Rocky Mountain Research Station. In September he will be the Director of the USFS’ new Office of Learning …. On April 10, 2015, Dr. Ivan Pupulidy also made some PUBLIC comments during the following PUBLIC discussion between other Type 1 IHC Superintendents about the ‘Yarnell Hill Fire’ and what these other Type 1 IHC Superintendents called the “BOTCHED investigation of the Yarnell Hill Fire.”
Type 1 IHC Superintendent Don Feser said ( during this PUBLIC discussion ) … “What I have read regarding Yarnell doesn’t pass the smell test." And USFS employee Dr. Ivan Pupulidy ( and author of the new USFS accident investigation protocol ) said “When will we give up SECRETS to keep our friends ALIVE?”
Within the aforementioned WFT article (2014 or 2017) on the CRaP, you will find this quote in their paper:
“Actions and decisions are consequences, not causes. The goal is to understand why actions or decisions made sense to those involved at the time. Conditions shape decisions and actions, revealing these conditions will aid the agency and agency personnel in understanding how to recognize, change and react to conditional pressures.” (emphasis added)
ACTIONS AND DECISIONS ARE CONSEQUENCES, NOT CAUSES. Really? I thought that “actions” based on “decisions,” actually “caused” or resulted in consequences, whether good or bad. However, I agree with the “sensemaking” portion of the CRaP.
Part of what this comes to is that if a decision is not caused, there is no standard explanation of it and if maybe there is no explanation of it – what other kind of explanation of events is there but a standard causal one? The CRaP quote sounds a lot like the notion of DETERMINISM. Determinism is the doctrine that all events, including human action, are ultimately determined by causes external to the will. So then, nobody is to blame because it’s no one’s fault. It’s just one of those things that happened as PFD WBC Willis stated at the July 2013 YHF GMHS Fatality Site news Conference.
It looks like the CRaP implies that individual human beings have NO FREE WILL and CANNOT BE HELD MORALLY RESPONSIBLE FOR THEIR ACTIONS. And here lies the rub. Where are the Lessons Learned if nobody is ever going to be found to have made any bad decisions that resulted in bad outcomes, including wildland fire burnovers and/or fatalities? Could this be the result of WF training instructors telling their students: “There are no wrong answers.”
Another new version of investigation is the alleged “Learning Review.” This quote appeared on the cover: “The greatest obstacle to discovery is not ignorance! – it is the illusion of knowledge” by Daniel J. Boorstin. I will revisit this again. This is directly from the Saddleback Learning Review where a Smokejumper was killed from a hazard tree incident on the Modoc NF near Alturas in northern California.
This learning review began with its purpose and then the question: “If we don’t find fault, what can we do? The aim of this Learning Review is to understand the rationale for the actions/decisions involved in the incident and then, if possible, to learn from them. Achieving this goal requires a deliberate effort to place decisions and actions in the detailed context in which they occurred …” (emphasis added) (pp. 2-3)
Notice the two separate variations of “actions” and “decisions.” Now pay attention to the subtle, deceptive sleight-of-hand transformation on page 14 under “Building Context Around Actions and Decisions.”
“There were a variety of different factors and pressures influencing actions/decisions. (Footnote 9) (emphasis added)
“(Footnote 9) There were occasions in the Review where the difference between actions and decisions could not be separated, thus the term action/decision was used, as it could have been either one, or a combination of both.”
The Saddleback Learning Review Members used this Daniel J. Boorstin quote: “The greatest obstacle to discovery is not ignorance! – it is the illusion of knowledge.” Was this a clever hint of what was to come? However, reanalyzing this changes this to more accurately mean ‘the greatest obstacle to discovery is the illusion of knowledge’ because of how they twist the definitions and manipulations of “actions” and “decisions,” (i.e. “the illusion of knowledge”).
“Action” is defined as the fact or process of doing something, typically to achieve an aim. And “decision” is defined as a conclusion or resolution reached after consideration or the action or process of deciding something or of resolving a question.
“To respect words and their conveyance of reality is to show respect to the very foundation of reality. To manipulate words is to seek to manipulate truth and to instead choose falsity and illusion over reality. The manipulation of words is itself a violent act. It is an act of self-centered pride ultimately doomed to frustration and failure precisely because it is based in falsity.” (Words: Pieper’s "Abuse of Language, Abuse of Power") (emphasis added)
Some say the PFD WBC Darrell Willis considered the GMHS his sons. In shock, he defended their fatal actions as well as the PFD actions in a July 2013 News Conference at the YH Fire Fatality Site. The WBC held structure protection as a higher priority over WF safety. ‘… no WF is satisfied stuck sitting in a Safety Zone (SZ) while structures were being threatened.’ These are strong indicators of conflicting values of many Municipal FDs that also fight wildfires. Confusion, frustration, and doubt - known hazardous barriers - may encourage potential human failures on wildfires when structures are threatened. GMHS McDonough is a prime example. During the investigation, he was asked if the GMHS knew of and followed the “10 & 18.” Likely coached, he commented something to the effect of, We had issues with #10, [Fight fire aggressively having provided for safety first] it’s old, that’s hillbilly … we’re a lot smarter than that. Obviously, third year WFs do not come to those conclusions on their own, so it’s a permissible inference that this PFD GMHS attitude was prevalent to at least some of the GMHS.
It is important to discuss this topic at this juncture. Groupthink symptoms are: a) illusion of invulnerability, b) illusion of morality, c) rationalization, d) stereotyping, e) self-censorship, f) illusion of unanimity, g) contrarian condemnation, and h) reliance on cognitive gatekeepers to maintain the status quo. Groups harmfully affected by Groupthink ignore safer alternatives as occurred on the YH Fire when the GMHS decided to leave their SZ. Do you think it would be best to exclude the 4-5 GMHS Rookies from the toxic Groupthink because they were taught to follow their trusted leaders and so they deferred to their trusted leaders’ expertise and died? The conventional belief among many WFs is that these betrayed young men were the true heroes.
In the PFD GMHS Handbook or Standard Operating Procedures, it requires these WFs to “be nice.” This is a hazardous way to do business in the inherently dangerous job of wildland firefighting. Disagreeing with someone making a bad decision with the potential for a bad outcome may require being other than “nice” to get one’s point across. And according to Dr. Putnam, the “be nice” plan is ineffective in investigations as well, when they are required to ask the tough questions seek out what is required to find the truth of what actually led up to what happened and why. The depth of true Serious Accident Investigations (SAIs) is diminishing due to the above new found Learning Reviews, CRaPs finding no fault, no in-depth Human Factors discussions, no in-depth Decision Making, and no in-depth Situational Awareness inquiries.
In future posts we will discuss/examine how the different agencies interpret fire weather and the resultant fire behavior.
I value the “Old School” method of learning from the past. Disturbingly, one of the investigators on the July 30, 2015 Frog Fire Fatality Investigation on the Modoc NF asked several young WFs if they had studied in their training about the historical fires, such as Mann Gulch, South Canyon, Kramer, and 30-Mile Fires. The young WFs commented that those fires were too old to benefit from and that their new standard was now the YH Fire.
Recently, this same distressing sentiment was shared when talking with some young USFS Hot Shot WFs. They said that “Dr. Ted Putnam used to be the trusted and respected source, but now he is passé” and his views are on the way out.” They added that the “YH Fire SAIT are the new system taught.” They also added that another “investigator” and now USFS Risk Management Branch Director Steve Holdsambeck are the “new” Dr. Putnam of today. So, I asked them: “are you kidding me? Did you just say Steve Holdsambeck? The guy at the recent April 2018 San Diego Wildland Fire Safety Summit who stated that they first come to a conclusion then fill in the rest, compared to Dr. Putnam who refused to sign off on a cover-up on the South Canyon Fire? And they have never attempted to correct any of these prior SAIT-SAIRs.” These young HS quickly switched subjects and the discussion ended.
It is readily apparent in the Southwest that WFs are not allowed to openly discuss the YH Fire and deaths of the GMHS, so I found the reply from them "whacked - out."
Learning from “old timers” and wanting to embrace the “old + (plus) new” compared to the way it is, “old vs new” is dangerous.
We need to learn from history. George Santayana is famous for his quote: “Those who do not remember the past are condemned to repeat it.”
The next post I will be sharing will be several fire weather and fire behavior photos and videos from the June 30, 2013, YH Fire. I have a lot of YH Fire data to disclose and rather than dumping it out all at once in a Dropbox, I will post it out little by little with explanations to the best of my abilities. These photos and videos will specifically support the basis of my June 27, 2018, question: “Did the late afternoon, June 30, 2013, Sesame Street and The Shrine fire behavior/smoke plumes influence structure loss and GMHS fatalities?”
In closing, I consider USFS Blue Ridge Hot Shot (BRHS) Supt. Brian Frisby to be the finest WF supervisor in the United States. On the June 30, 2013 YH Fire, Frisby and the BRHS took over as the Division Z DIVS when AZ BLM employee Rance Marquez, as WFs have explained it to me, he basically abandoned his Division. Yet, I think Rance maybe holds the key to some missing elements of the YH Fire. Frisby became the ad hoc DIVS Z and accepted responsibility for the tactics and strategy and safety and welfare of those in the Division (Z) while his Assistant Trew Brown supervised the BRHS. As I post photos and videos, maybe Frisby will share why there was nothing about WFs near the Helms on the ridgeline/ridgetop in the SAIT and ADOSH reports, as evidenced in the photos you are about to see.
Contrary to the SAIT - SAIR and ADOSH conclusions, I am about to share a little sample that there were WFs in that area near the Helms. Currently pulling metadata and formatting the original copies and at a later date will share those.
There are more photos and videos yet to be revealed, so stay tuned ...
Figure 2. Video - active fire behavior (3:55 PM, June 30, 2013) Source: Anonymous-by-request persons
Figure 3. Video - (3:55 PM, June 30, 2013) Active fire behavior. Source: Anonymous-by-request persons
Figure 4. Screenshot - idealized map indicating from where local residents took photos (yellow stars #1 and #2); Fire Break, Shrine, and Sesame Street Fire Break, BSR (Helms), Wash (chute) area, and GMHS Deployment Site. Note the Fire Break, wash (chute), and GMHS Deployment Site alignment. (June 30, 2013) Source: Google Earth
Figure 5. Screenshot - unidentified WF standing on a ridgeline overlooking the YH Fire. (Actual photo time is still under evaluation of the metadata) Source: Laurie Colvin
Figure 6. Screenshot - active fire behavior along ridgeline. (Actual photo time is still under evaluation of the metadata) Source: Laurie Colvin
Figure 7. Screenshot - active fire behavior along ridgeline. (Actual photo time is still under evaluation of the metadata) Source: Laurie Colvin
Figure 8. Screenshot - active fire behavior along ridgeline. (Actual photo time is still under evaluation of the metadata) Source: Laurie Colvin
Figure 9. Screenshot - two unidentified WFs standing on a ridgeline overlooking the YH Fire.(Actual photo time is still under evaluation of the metadata) Source: Laurie Colvin
Figure 10. Screenshot - two unidentified WFs standing on a ridgeline overlooking the YH Fire with active behavior below them. (Actual photo time is still under evaluation of the metadata) Source: Laurie Colvin
Figure 11. Screenshot - unidentified WF standing on a ridgeline overlooking the YH Fire. (Actual photo time is still under evaluation of the metadata) Source: Laurie Colvin
Figure 12. Screenshot - active fire behavior along ridgeline. (Actual photo time is still under evaluation of the metadata) Source: Laurie Colvin
Figure 13. Screenshot - Unidentified WF on ridgeline with active fire behavior along ridgeline. (Actual photo time is still under evaluation of the metadata) Source: Laurie Colvin