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Were Wildland Fire Fatality Staff Rides, based on revisiting Military Battlefields, designed to be a

Were Wildland Fire Fatality Staff Rides, based on revisiting Military Battlefields, designed to be a unique method to convey the "complete" wildland fire lessons learned of the past to the present day Wildland Fire Leaders? ( Part One )


2019-06-29 | Arizona Desert Walker Joy A. Collura and contributing other(s)



Views expressed to "the public at largeand "of public concern"


DISCLAIMER: Please fully read the front page of the website (link below) before reading any of the posts ( www.yarnellhillfirerevelations.com )

The authors and the blog are not responsible for misuse, reuse, recycled and cited and/or uncited copies of content within this blog by others. The content even though we are presenting it public if being reused must get written permission in doing so due to copyrighted material. Thank you.

Due to the controversial nature of the topic, some content and/or analyzed content may include subject matter considered by some to be graphic, disturbing, and/or offensive by some standards. It has never been the intention to create any harm or hurt. This is so that pure, true lessons can be learned.


What follows is a closer look at the significance of wildland fire Staff Rides, followed by numerous photos from June 30, 2013, that were witnessed and photographed by us, the two Eyewitness Hikers. The black font, sometimes bolded, is from the sources cited and the authors' comments to others are in green, sometimes bolded green, in response to their comments.

Staff Rides are generally based on investigations, so a research paper citation and a brief quote from Dr. Ted Putnam, a psychologist and former USFS lead human factors investigator, are in order here. “… Recently some investigations have recommended relating the accident in a story format to increase readability, interest and learning within firefighter safety cultures. Generally the goal of accident reports is to convey as much of the truth of an event that is discoverable. … Sometimes investigators deliberately distort or do not report all the causal elements. …” (emphasis added)

Source: (Putnam, T. 2011) Accidents, accident guides, stories and the truth. International Association of Wildland Fire (IAWF) Ironically, the Wildland Fire Lessons Learned Center (LLC) will NOT post or publish this informative paper in spite of over a dozen attempts by Dr. Putnam and others. It is published only on this blog (October 15, 2018) and on Academia.edu.

Dr. Putnam's disdain and distrust of wildland fire fatality investigations and the ensuing Staff Rides is quite evident here: 'Once firefighter and investigator lies about fatality fires get written into official reports, staff rides only turn the lies into dramas. Even if the Truth later seeps out, the staff rides keep regurgitating the same original lies. The net effect is firefighters keep dying for the same reasons. We lie to protect our imaginary personal, crew and agency images and real firefighters keep suffering and dying to nourish those collective fragile egos. We told the real truth during the Battlement Creek Staff ride development; none of it ever got incorporated into that staff ride. There is very little learning at the Lessons Learned Centers.’ (emphasis added) (Putnam - during Staff Ride Development phase)

This theme from Dr. Putnam's paper is weakly reinforced here in a researcher titled: DO STAFF RIDES HELP MOVE THE FOREST SERVICE TOWARD ITS GOAL OF BECOMING A LEARNING ORGANIZATION?” This is a Thesis / Project work submitted in partial fulfillment of the requirements for the Master of Science in Human Factors and System Safety by Joseph R. Harris for Lund University Sweden.

From the paper above, we will go to the conclusions section to delve into Harris's summation on the subject.

"CONCLUSIONS (p. 29)

"Staff rides are highly valued learning products, and could contribute to the Forest Service’s mission to become a learning organization. There is also a perceived gap between the traditional written report and the staff ride. The Forest Service can make progress toward its goal of becoming a learning organization by closing this gap through designing learning products that aim to replicate the emotional and intellectual impact of the staff ride to a much wider audience. ...” (all emphasis added)

( https://www.wildfirelessons.net/viewdocument/do-staff-rides-help-move-the-forest-1 )

Harris' conclusions that "staff rides could contribute to the Forest Service’s mission to become a learning organization" are accurate only if they change from a deceptive and cover-up culture to one that is ethical and forthright. Additionally, the "perceived gap between the traditional written report and the staff ride" is an understatement; a subtle attempt at softening a very devious action concealing the truth.

You may recall that this is the very same USFS Human Dimensions Specialist Joseph R. Harris that BRHS Supt. Brian Frisby emailed in 2016 regarding the YH Fire Staff Ride development posted on October 15, 2018, on the www.yarnellhillfirerevelations.com at Figure 10. The BRHS Supt. Brian Frisby email thread with USFS National Human Dimensions Specialist Joseph Harris and USFS COF employee LaVelle Shelton regarding the YH Fire Staff Ride. Source: FOIA Request ("From: Frisby, Brian H -FS Sent: Tuesday, April 12, 2016 10:08 AM To: Harris, Joseph R - FS Subject: Human Factors!")

"Woe unto them that call evil good, and good evil; that put darkness for light, and light for darkness; that put bitter for sweet, and sweet for bitter!" (Isaiah 5: 20 KJV)

Figure 1. One of the last photos taken by us hikers of the Granite Mountain Hotshots hiking up the 2-Track Ridge of the Weaver Mountains on morning of June 30, 2013, 9:22 AM - taken by me after I passed them I turned around and took this photo. Note the rolled up sleeve on at least one of the sawyers and the fire edge (4 tiny bushes) is just .03 miles away (around the corner).

"No one will be able to stand against you all the days of your life. … Be strong and very courageous. … for the Lord your God will be with you wherever you go.” Joshua 1:5-9 (NIV)

Facts are stubborn things; and whatever may be our wishes, our inclination, or the dictates of our passions, they cannot alter the state of facts or evidence.” John Adams (1770)

Source: thisdayinquotes.com

What follows is a moderately extensive examination of "wildland fire staff ride" search resulting from (GTS) Google That Shit Internet specifically for the phrase: "wildland fire staff ride."

Covered elsewhere on this blog, Staff Rides Part 1 and 2 (December 7, 2018) consider now a brief discussion on Staff Rides. Source: Wildland Fire Leadership

Staff rides were developed by the Prussian Army in the early nineteenth century and have been used by the military in many countries since then. In the 1970's the U.S. Army and the U.S. Marine Corps turned to staff rides with great enthusiasm and now they are considered essential instructional techniques in advanced military schools and in field units.” (all emphasis added)

The intent of a staff ride is to put participants in the shoes of the decision makers on a historical incident in order to learn for the future. … [and] should not be a tactical-fault finding exercise. Participants should be challenged to push past the basic question of ‘What happened?’ and examine the deeper questions of leadership and decision-making: [1] ‘What would I have done in this person's place?’ [2] ‘How detailed should the guidance from a superior to a subordinate be?’ [3] ‘Can a senior leader make use of a competent but overzealous subordinate?’ [4] ‘What explains repeated organizational success or failure?’ The study of leadership aspects in a staff ride transcend time and place.” (all emphasis added)

“A [Staff Ride is a] field study that is conducted on the ground where an incident or event happened. A staff ride consists of three distinct phases:

- a systematic Preliminary Study of a selected fire or other emergency operation, - an extensive Field Study to the actual site(s) associated with the incident, - and an opportunity for Integration of the lessons derived from the study and visit.

“Staff Rides require maximum participant involvement before arrival and at the site to guarantee thoughtful analysis and discussion."

A staff ride should avoid being a recital of a single investigation report. Such reports rarely address the human factors that affect individual decision-making. For this reason, providing participants with a variety of information sources is important." (italicized emphasis original)

The YH Fire indeed requires "a variety of information sources" in order for this particular YH Fire Staff Ride of an epic wildland fire tragedy to even be close to achieving accurate and factual status.

A newer version of the NWCG Leadership Toolbox on Staff Rides has a new "fictional drama" angle. "While an investigation report is a primary source of information, it should not be the only source of information that is used. Facilitators are encouraged to rent and watch the movie Courage Under Fire. Although this movie is a fictional drama, it provides a good perspective on the barriers that can be encountered during an incident investigation." (emphasis added) (https://www.nwcg.gov/wfldp/toolbox/staff-ride)

So then, we are being asked to avoid second guessing or being judgmental of decisions and actions, yet encouraged to view a fictional drama for discussion instead? Is that to complement the fictional foregone "conclusions" from the SAITs and / or Review Teams and mollify us to their deceptions and lies in their conclusions of "no violations of negligence, policy, protocol, or procedure"? And where is the Human Factors section of the SAIT-SAIR? It is non existent!

"Wildland Fire Leadership - A forum where students of fire and leadership come together to discuss, debate and exchange leadership development concepts, experience, and thoughts with an intent to promote cultural change in the workforce and strengthen the wildland fire service and the communities they serve." (all emphasis added) Source: BLM_FA_Leadership_Feedback@blm.gov, contact Pam McDonald at (208) 387-5318 or pmcdonal@blm.gov.

"Tuesday, June 14, 2016 - No Two Staff Rides are Ever the Same"

( http://wildlandfireleadership.blogspot.com/2016/06/no-two-staff-rides-are-ever-same.html )

"No two staff rides are ever the same. Regardless of how many times a participant attends, differences occur and something new is learned. One reason for this is the audience background or experience and the perceptions each participant brings to the staff ride and how those items are woven into staff ride discussions." (emphasis added)

"Conducting a staff ride with a mixed audience creates an experiential learning environment where everyone benefits and learns. Line officers, who are an importation [sic] part of firefighter safety and leadership, add volumes to leadership training experience both on and off the fireline." (emphasis added)

They should be different only from the perspective of the different participants' and their conclusions, take always, and the like. However, the key item that should remain the same as the basis for these Staff Rides, is the truth of the matter. What really happened and why did it happen? The truth of the matter MUST be the basis for the Staff Ride in order for the participants to base their perspectives on.

"Firefighters learn from the Battle of San Pasqual - A Staff Ride to the battlefield" - April 26, 2019 - a guest article written by Heather Thurston.

( https://wildfiretoday.com/tag/staff-ride/ )

"The study of infamous fires and military battles can be a valuable learning opportunity for wildland firefighters. On a Staff Ride, finding out about leadership factors that affected the outcome can help participants benefit from the good decisions, and reduce the chances of making similar mistakes." (emphasis added)

One would think it necessary that properly examining "leadership factors that affected the outcome can help participants benefit from the good decisions, and reduce the chances of making similar mistakes" would entail actually discovering the "factual" information regarding this important causal matter.

"... at a riverbed. Once Captain Pico realized his troops were are getting boxed in by the US, he faked a retreat down into this riverbed. Here, you can start to see more active participation by the academy cadets, as lessons learned from their studies into incidents such as the Yarnell Hill Fire start to connect and draw a parallel to the decision making processes of this battle. Instructors reiterate leadership lessons that had been touched on throughout the day and how they all led to the battle that happened on this very ground." (all emphasis added)

What lessons were learned from their studies into incidents such as the Yarnell Hill Fire to start to connect and draw a parallel to the decision making processes of this Battle of San Pasqual? Because this is the first time the YH Fire is mentioned, what are these alleged lessons learned based on facts and truth or on the musings of the SAIT-SAIR?

"... students, mentors, and instructors alike are asked to draw conclusions about the battle’s relevance today. A voice inside me says, “Be hungry for your history”, meaning learn these lessons from others’ mistakes when the time/decision making wedge is wide. ... And above all, never stop learning." (all emphasis added)

First off, did these students actually examine the YH Fire in order to "learn these lessons from others’ mistakes" on "incidents such as the Yarnell Hill Fire." And how are we to "learn these lessons from others’ mistakes" on "incidents such as the Yarnell Hill Fire" if we are not given the truth about what happened on June 30, 2013, and why?

"Becker, Wendy and Burke, Michael, The Staff Ride: An Approach to Qualitative Data Generation and Analysis (2012). Organizational Research Methods, 15(2), pp. 316 - 335, 2012."

( https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2119118 )

The words, fact, facts, factual are mentioned three times. So then, it appears that "facts" do matter at least for these authors.

Citing author John Maclean on pages 8-9 (Running head: The Staff Ride: An Approach to Qualitative Data Generation and Analysis by Wendy S. Becker and Michael J. Burke of Shippensburg University Tulane University Becker.

"Maclean’s retrospective analysis of the smokejumpers at Mann Gulch demonstrates the value of independent, review of an event outside of the organization in which an event occurred: The Forest Service moved quickly, probably too quickly, to make its official report and get its story of the fire to the public. It appointed a formal Board of Review, all from the Forest Service…it is hard to see how in such short time and so close to the event and in the intense heat of the public atmosphere a convincing analysis could be made…In four days they assembled all the relevant facts, reviewed them, passed judgment on them, and wrote what they hoped was a closed book on the biggest tragedy the Smokejumpers had ever had (Maclean, 1992, p. 148)." (all emphasis added)

( https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2119118 )

"A positivist or postpositivist approach to staff rides could develop a generalizable theory using evidence accumulated through deductive processes, including literature reviews and gathering new data; the goal would be to uncover facts or collect data which can be compared to hypotheses or propositions previously developed.." (all emphasis added) p. 10

Consider now some of the conventional wisdom on the terms "positivist" and "postpositivist" and how they relate to our topic on Staff Rides. It may be somewhat esoteric to some of you, however, you will need to understand the terms used in the research paper and what they mean. So, bear with us.

Source: Kivunja, C. and Kuyini, A.B. (2017) Understanding and Applying Research Paradigms in Educational Contexts. International Journal of Higher Education, 6 ( http://www.sciedu.ca/journal/index.php/ijhe/article/download/12169/7683 )

"The Positivist paradigm defines a worldview to research, which is grounded in what is known in research methods as the scientific method of investigation. ... the Positivist paradigm refers to the researcher’s attempts to explain the phenomena they study in the most economic way possible" (p. 30) (all emphasis added)

"The following summary should help you to understand the basic characteristics of research that is normally located within the Positivist paradigm, citing Neurath (1973) and Fadhel (2002).

o A belief that theory is universal and law-like generalisations can be made across contexts.

o The assumption that context is not important

o The belief that truth or knowledge is ‘out there to be discovered’ by research.

o The belief that cause and effect are distinguishable and analytically separable.

o The belief that results of inquiry can be quantified.

o The belief that theory can be used to predict and to control outcomes

o The belief that research should follow the Scientific Method of investigation

o Rests on formulation and testing of hypotheses

o Employs empirical or analytical approaches

o Pursues an objective search for facts

o Believes in ability to observe knowledge.

o The researcher’s ultimate aim is to establish a comprehensive universal theory, to account for human and social behaviour.

o Application of the scientific method

(all emphasis added above)

It's interesting that the researchers consider "The belief that truth or knowledge is ‘out there to be discovered’ by research"

On the other hand, the "Postpositivist paradigm accepts that reality is imperfect and that truth is not absolute but probable. ... the Postpositivist ... accepts that reality can never be fully understood; but at best, only approximated. Accordingly, the Postpositivist paradigm has tended to provide the worldview for most research conducted on human behaviour typical of educational contexts." (all emphasis added)

"In the strict positivist sense, this criterion requires that as far as possible, you, the researcher, should remain distanced from what you study so that the findings of your research will depend on the nature of the data rather than on your preferences, personality, beliefs and values." (all emphasis added)

The researchers note that "the goal would be to uncover facts or collect data which can be compared to hypotheses or propositions previously developed." (all emphasis added) One would hope that the goal of researchers and / or investigators would and should be to always "uncover the facts." (all emphasis added)

"If appropriate for the purposes of the staff ride, interviews with witnesses can be limited to simple questions about hard facts and concrete events (as opposed to abstract opinions and beliefs) because people demonstrate greater recall when incidents are deemed ‘critical,’ citing Chell (2004). " (all emphasis added)

In this site and on our posts, it it is always appropriate to focus on the "hard facts and concrete events (as opposed to abstract opinions and beliefs)" that were discussed. Professional opinions are often considered and always welcome from WFs and FFs engaged in wildland firefighting.

Wendy S. Becker and Michael J. Burke Academy of Management Learning & Education Vol. 13, No. 4

Research & Reviews - Instructional Staff Rides for Management Learning and Education (Published Online: 24 Oct 2013)

Abstract

"Staff rides—planned learning events that recreate a significant historical incident while engaging participants in open reflection and dialogue—offer many advantages for developing managers, yet they are relatively underutilized in management learning and education. Developed over a century ago, military staff rides develop leadership and decision-making skills and are an early example of psychological empowerment in that officers participate in planning battle strategy, yet are also trusted with making individual operational adjustments in the heat of the battle. Grounded in experiential learning theory, the case study, and critical incident methodology, staff rides involve a preliminary study of the historical event, a visit to the field, and an integration phase. Popular today for wildland fire, and public health in addition to military instruction, staff rides are unique in engaging participants in active exchange of information, reflective thought, and collective analysis of the event under study. ... " (all emphasis added)

We completely agree that the leadership and decison-making skills for making individual operational adjustments in the heat of battle is critical in wildland firefighting. Indeed, "staff rides are unique in engaging participants in active exchange of information, reflective thought, and collective analysis of the event under study," however, a caveat is in order here.

The "active exchange of information, and reflective thought" are acceptable in our view. However, the "collective analysis of the event" is another matter and it is because it implies somewhat of a Groupthink attitude requiring that all must agree and that independent thought, necessary in an independent review or investigation, is discouraged. The YH Fire GMHS tragedy was a collective event that resulted from its own form of Groupthink and that certainly requires examination by individuals in search of the truth instead of a "collective analysis of the event."

I have been for years documenting and fact checking the firefighters who stated, "we had to meet in Prescott at a hotel after June 30, 2013, and make sure all our notes matched versus what we individually experienced that weekend."

Source: US Forest Service Fire Management Today (FMT) Vol. 62, Fall 2002. Dude Fire Staff Ride issue

( https://www.fs.fed.us/sites/default/files/fire-management-today/62-4.pdf )

"HUMAN FACTORS IN FIRE BEHAVIOR ANALYSIS: RECONSTRUCTING THE DUDE FIRE" Karl E. Weick

Recounting the anecdote about a municipal FF trapped in a burning building, the author notes: "Later, when visibility was better, she realized that what she had thought was an attic stairway was in fact a chair standing against a wall." (all emphasis added)

Consider how the Staff Ride for this particular near-fatal incident would have been analyzed if the "fact" about the chair standing against a wall was ignored or disallowed in as part of the evidence introduced for participants to utilize in their analysis? That "fact" would have completely changed the story of what occurred.

Quoting Alexander, "It is my personal view that most fire behavior forecasts are not worth the paper they are written on—they are too general, and the [Fire Behavior Analyst] FBAN has not risked putting his/her name to a forecast that is very specific. We tend to use opaque words like ‘extreme,’ ‘erratic,’ etc., maybe even hiding under the fact that the numbers generated by Rothermel’s model are only accurate within a factor of 2.” (all emphasis added)

Once again, authors talking about Staff Rides and talking about "facts," so there must be something to that pesky fact thing.

Mining Our Past Following the Dude Fire Staff Ride

"I was haunted by the fact that—in spite of the information provided to the participants in a three-ring binder titled “Dude Fire Staff Ride Preliminary Study” and the 17 ­minute excerpt on the Dude Fire from the NFES (1998a) video— there still seem to be many unan­swered questions and perhaps conflicting opinions. Admittedly, some questions might never be definitively answered. However, new information has emerged as a result of undertaking the staff ride of the Dude Fire. ... , the fact that fuels had accumulated in the area for at least 30 to 35 years is not documented anywhere in the literature on the Dude Fire; yet this general concern with respect to firefighter safety has been enunciated elsewhere, espe­cially with respect to the wildland– urban interface (e.g., Mutch 1994; Williams 1995). (all emphasis added) Source: Alexander, M. (2002) "THE STAFF RIDE APPROACH TO WILDLAND FIRE BEHAVIOR AND FIREFIGHTER SAFETY AWARENESS TRAINING: A COMMENTARY" FMT, 62

Consider if this "new information [that] emerged as a result of [the Dude Fire Staff Ride]" had never emerged and was never introduced? The low fuel moistures would have still been factual. Just because it has never been introduced, does it make it any less factual or valuable as evidence?

And how about this gem? " ... the fact that fuels had accumulated in the area for at least 30 to 35 years is not documented anywhere in the literature on the Dude Fire; yet this general concern [documentation] with respect to firefighter safety has been enunciated elsewhere, espe­cially with respect to the wildland– urban interface ..." (all emphasis added) Because it is unlisted in the Dude Fire information sources, and "enunciated elsewhere" still qualifies it as a beneficial source for studying WF safety in the urban interface.

"Jim McFadden of the California Department of Forestry [CDF] Fire Academy on California fatality fire case histories given at the Forest Technology School in Hinton, AB, in the mid-1980s. His case studies certainly emphasized the importance of human factors as well as fire behavior as contributing factors ..." (all emphasis added) Source: Alexander, M. (2002) FMT, 62, p. 28

Human factors, almost always ignored and unexamined in wildland fatality fires is clearly recognized as among many "contributing factors ..." by CDF training instructor Jim McFadden in their Fire Academy. So then, it should also be considered as important in Staff Rides as such as well. (all emphasis added)

NEXT STEPS IN WILDLAND FIRE MANAGEMENT Source: Williams, J. (2002) FMT, 62, pp. 31-35. Jerry Williams was the Director of Fire and Aviation Management, USDA Forest Service, Washington Office, Washington, DC. and what follows is based on remarks made by the him at the National Fire and Aviation Management Meeting from February 25 to March 1, 2002, in Scottsdale, AZ.

We will include almost all of Mr. William's article, only excluding the Fire Use Projects and some other select excerpts.

"Wildland fire is a high-risk, high-consequence business. It is influenced by high social expectations and a low political tolerance for failure. Our environment is surrounded by uncertainty and danger. It is con­trolled more and more by our ability to measure, manage, and mitigate risk. (all emphasis added)

"In our history, every meaningful advance in wildland fire operations has been marked by some reduction in uncertainty or mitigation of risk, almost always following some accident or tragedy. Our under­standing of fire behavior, the technological advances in the tools we use, the protective qualities of the gear we wear, the training we employ, and even some of the early explorations of what we call “hu­man factors” have all made our work safer. (all emphasis added)

Still, the tragedies at Dude, South Canyon, and Thirtymile and the accident at Cerro Grande remind us of the danger that is always present in our world.** [For more on the Dude Fire, see the related articles in this issue; for the other incidents, see Bret W. Butler and others, “The South Canyon Fire Revisited: Lessons in Fire Behavior,” Fire Management Today 61(1): 14–20; Hutch Brown, “Thirtymile Fire: Fire Behavior and Management Response,” Fire Management Today 62(3) [in press]; and “‘Remember Los Alamos’: The Cerro Grande Fire,” Fire Management Today 60(4): 9–14.] (all emphasis added)

"The necessary next steps will represent a profound change in how we plan and execute the high-risk, high-consequence fire program that we are charged with leading.

Managing Risk

"We face a wide variety of pressing issues, including contracting, training, the initial abatement plan from Thirtymile, leadership, workforce diversity, and the Na­tional Fire Plan. Moreover, we must not overlook preparedness for the fire season that lies ahead. Each of these issues deserves our careful attention; we need to work on all of them. However, I want to get us thinking about our vulnerabilities. I want to make the point that opera­tional professionalism needs to be measured in terms of our ability to better manage the risks that sur­round us. (all emphasis added)

"... reflecting on where this program is right now. What has changed around us? Where do we need to direct not only our management energy, but also our leadership energy? (all emphasis added)

"Karl E. Weick and Kathleen M. Sutcliffe, in their work Managing the Unexpected, examined what they call high-reliability organiza­tions in “exotic” lines of work, including wildland firefighting. [Article review p. 36] The authors found that high-reliability organizations, despite the trying conditions around them, have “less than their fair share of accidents.” They attribute our overall success to our determined efforts to notice the unexpected in the making and stopping its devel­opment. ... if we have difficulty halting the development of the unexpected, we focus on containing it. And if ... compromised, we focus on resilience and rapid restoration of function. (all emphasis added)

"[They] also note that, when we’re successful, we maintain a high state of situational aware­ness. Yet when we fail, we make it our habit to bounce back from tragedy, knowing that tragedy— however unwanted—is an ever-present threat in wildland fire operations. As they put it, we are “pre-occupied with failure.” Perhaps ironically, then, our growth and improvement depend on the very introspection that accompanies failure. (all emphasis added)

"Operationally, ... we are absolutely tenacious in becoming sharper and safer. However, in the past few years, a recurring pattern suggests that we may need to go beyond mere operational fixes. The pattern is based on four events:

Dude Fire (1990), 6 fatalities;

South Canyon Fire (1994) 14 fatalities;

Cerro Grande Fire (2000), 235 homes damaged or destroyed; and

Thirtymile Fire (2001) 4 fatalities.

(all emphasis added)

"The Ten Standard Firefighting Orders must be firm rules of engagement. Mistakenly, we may be focusing our fixes only on the margins." (all emphasis added)

"The Challenge

"Weick and Sutcliffe challenge us as managers to maintain an “aware­ness of discriminatory detail” and focus on our “ability to discover and correct errors that could escalate into a crisis.” At the operational level, we have reacted to errors quickly. Over the past several years—in response to the four events described above—we have focused on policy and process. ..." (all emphasis added)

"I do not wish to demean any of these improvements. However, I believe that we need to go beyond the fixes that we have traditionally relied on. The necessary next steps will represent a profound change in how we plan and execute the high-risk, high-consequence fire pro­gram that we are charged with leading.

>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>

"There are four steps we can take to better measure, manage, and mitigate risk, ranging from our activities on the fireline to the plans that guide us:

Make our rules of engagement firm,

• Improve our extended-attack operations,

• Position ourselves for long-duration, landscape-scale fire use projects, and

• Address fire-related issues in our land management planning. (all emphasis added)

"The four steps are tied to our Brookings Strategic Agenda and consistent with our Fire and Aviation Management Program Emphasis, the two documents that emerged from our Fire Directors’ Meetings, respectively, in Denver, CO, on March 27–29, 2001, and in Portland, OR, on December 4–6, 2001.

We have been unable to locate this referenced research paper. Extensive GTS searches reveal only references to the paper itself.

"Firm Rules of Engagement

"The Ten Standard Firefighting Orders must be firm rules of engagement. They cannot be simple guidelines, and they cannot be “bargained.” They are the result of hard-learned lessons. Compromis­ing one or more of them is a common denominator of all tragedy fires. On the Dude, South Canyon, and Thirtymile Fires, the Fire Orders were ignored, overlooked, or otherwise compromised. (all emphasis added)

"The Fire Orders mean little after we are in trouble. That is why we must routinely observe them and rely on them before we get into trouble. We know that no fire shelter can ensure survival all of the time under all circumstances. Entrapment avoid­ance must be our primary emphasis and our measure of professional operational success. (all emphasis added)

"Conditions on the fireline can rapidly change. In the pressure of the moment, it is easy for people to overlook something important. That is why we must encourage our firefighters to speak up when they notice safety being compromised. As Weick and Sutcliffe point out, “people who refuse to speak up out of fear enact a system that knows less than it must to remain effec­tive.” We must promote a working environment where even our greenest firefighters feel free to speak up. (all emphasis added)

"Following an accident, a “stand­down” should be an accepted practice for those involved, until the facts can be sorted out. How­ever, it is a shame that our focus on accountability too often occurs after an accident. Culturally, we must shift the weight of accountability to the time before an accident takes shape. We must embrace the rules of engagement as a way of doing business—as a professional stan­dard. Violation of any Fire Order must prompt management or supervisory intervention and, unless rapidly corrected, be unargu­able grounds for release from the fireline, release from the incident, or—if egregious—serious person­nel action. (all emphasis added)

"However, we must not adhere to the Fire Orders for fear of punishment. We must embrace the Fire Orders because we owe it to one another. In that sense, the Fire Orders must become a shared obligation, where the leader’s situational awareness depends on participation by the entire crew and where the crew’s participation is tempered with respect for the leader’s responsibil­ity. Borrowing from the aviation community’s model of Cockpit/ Crew Resource Management, we must focus fireline operations more on what is right than on who is right. (all emphasis added)

"Extended-Attack Operations

"About 90 percent of the wildfires we deal with are suppressed with little notice and effort and at minimal cost. By contrast, about 5 percent of our fires, virtually from the outset, are destined to become large, costly events. It is the fires in between that challenge us now. These are the fires that rapidly transition from relatively benign events to major conflagrations. They are among the most dangerous fires we face. (all emphasis added)

"Dude, South Canyon, and Thirtymile are our most recent examples of the tragedy that can result during extended-attack. ... Historically, some 70 percent of our fatalities are associ­ated with such transition fires. Extended attack typically occurs at high fire danger levels, when fatigue and drawdown at the crew level are exacerbated by slim management oversight and over­extended supervisory controls. The danger grows even greater because time is almost always compressed. (all emphasis added)

"Remarkably, we have strategies in place on both ends of the wildfire spectrum but no coherent approach to the fires in between. With few exceptions, we deal with transition fires as best we can with what we have and hope that we come out okay. Too often, we do not. As Weick and Sutcliff note, high-reliability organizations “differentiate between normal times, high-tempo times, and emergencies and clearly signal which mode they are operating in.” It is time we did the same for our transition fires. (all emphasis added)

"We need to take the next step by establishing risk thresholds that indicate impending danger. The thresholds will prompt us to position management oversight, supervisory control, and crew capabilities to more safely and effectively deal with the potential for extended-attack operations. The National Wildfire Coordinating Group has sanctioned this effort. We are working with the USDA Forest Service’s Research staff and with the Predictive Services Branch at the National Interagency Fire Center to have preliminary support in place by summer 2002.

"Though few, extended-attack fires are inarguably our most important fires. The danger that surrounds them and the consequences when we fail—in terms of costs, losses, and damages—are enormous. They deserve a more deliberate, more disciplined strategy.(all emphasis added)

"Land Management Planning

"Over the last 2 years, many people have focused on the viability of our fire management plans. Clearly, the plans need to be updated and completed. However, fire manage­ment plans are only as good as the land and resource management plans (LRMPs) they are based on. The Forest Service’s Line Officer Team, in its annual letter for 2002, encouraged regional foresters to give special attention to fire-related issues as LRMPs are revised. The letter reminds us that resource objectives are established in the LRMPs, not in the fire management plans; consequently, it is the LRMPs that set acceptable limits of social, economic, and ecological risk. Fire management decision space in terms of safety, cost, and risk is largely predetermined in LRMPs. Yet the LRMPs rarely get the after-action scrutiny that a wildfire should prompt when it destroys valuable resources and costs tens of millions of dollars to suppress.

"Weick and Sutcliffe note that high-reliability organizations are “reluc­tant to simplify the complexities that define their environment.” For most of us, LRMPs are cumber­some, complex documents that seem only indirectly related to safety, cost, and risk. For many of us, these plans seem abstract or obtuse in relation to the operational dimensions of wildland fire man­agement. Although the Forest Service typically spends about $600 million per year fielding a fire suppression force and another $500 million per year suppressing unwanted fires, we often lack enthusiasm for the large-scale LRMP revisions or amendments that might help reduce the poten­tial for destructive, high-intensity fires. (all emphasis added)

"Our reluctance comes at a cost. In drier forest types, inaction or poorly conceived resource objectives inadvertently favor dense, multi-storied stand conditions. The re­sultant fuel loads, especially during drought years, greatly increase fire intensity potentials. Therefore, the objectives set in LRMPs, however remote their effects might seem, directly bear on firefighter safety, suppression costs, and protection opportunities for communities at risk. Until we resolve the issues associ­ated with land management plan­ning, fuels will continue to accu­mulate and the improvements we make to our fire management plans will realize no more than marginal benefits. The next step is to look beyond our fire management plans and resolve some of the issues raised by the decisions we make in our land management planning. (all emphasis added)

Higher Level of Professionalism

"As wildland fire managers, we know that our most important resource is our workforce. In the uncertain, high-risk, high-consequence environment we work in, the measure of professionalism is a recognition of our vulnerabilities and an uncompromising respect for our limits. A developing workforce must rely on leadership to learn these lessons. As leaders, then, we must make safety more than a platitude. We must make it a responsibility. By “taking the next step,” I mean aspiring to a higher level of profes­sionalism in wildland fire opera­tions. As leaders, we each occupy a position of influence. We can influence policies and procedures; but even more important, we can influence our people through our values and beliefs. Our values should infuse our standards and shape our actions if they are going to mean something to our people. (all emphasis added)

CODE OF CONDUCT FOR FIRE SUPPRESSION

"As wildland fire managers, we must lead by observing these principles in our daily con­duct:

• Firefighter safety comes first on every fire, every time.

• The Ten Standard Firefighting Orders are firm. We don’t break them; we don’t bend them. • Every firefighter has the right to know that his or her assignments are safe. • Every fireline supervisor, every fire manager, and every administrator has the responsibility to confirm that safe practices are known and observed. (all emphasis added)

This was an interesting quote made by Mr. Williams: "... even some of the early explorations of what we call 'hu­man factors' have all made our work safer." To be fair, human factors has been used for quite some time in the research realm but not so much in the wildland fire fatality investigation realm, as evidenced in the June 30, 2013, YH Fire as well as other fatality wildfires mentioned above. Mr. Williams assertion that "explorations of what we call 'human factors' have all made our work safer" is worth a brief discussion.

The USFS and others have only talked about the issue of "human factors" from academic research (i.e. Reason (1990, 1995, 2000, 2016), Catino (2008, 2013), Dekker (2001, 2002, 2003, 2006, 2011, 2013, 2014, 2019), Snook (2000, 2002), Weick (1993, 1995), Vaughan (1996, 2018) and many others). The "human factors" mantra was bandied about in their upper management, however, it was the WFs and FFs who really focused in on the issue and applied it. It is both the exploration, and then the actual application of the true lessons learned from these studies in human factors that would surely make our work safer.

"Following an accident, a “stand­down” should be an accepted practice for those involved, until the facts can be sorted out. How­ever, it is a shame that our focus on accountability too often occurs after an accident." (emphasis added)

Yes it certainly is a shame. It seems like the wildland fire Agencies and those municipal agencies engaged in wildland fire suppression, for the most part, seem to be very reactionary, whereas the WFs and FFs "on-the-ground" are fairly proactive, and most often adhering to the basic wildland firefighting rules and guidelines noted above, thus thwarting and at least reducing tragedies. Except in the case of the YH Fire and the GMHS that had been drifting into failure for years after discounting and / or ignoring the human factors.

USFWS New Mexico Refuge Fire Manager a Leading Interagency Trainer November 2008

( https://www.fws.gov/fire/news/nm/trainer.shtml )

"To learn from the successes and failures of the past, in particular events which were of national significance to fire policy, and often included firefighter fatalities, the group sponsors “staff rides,” modeled after a military training technique utilized to review past battles.

"Wilcox, Fire Management Officer at the Bosque del Apache National Wildlife Refuge in New Mexico, has been involved in the development of multiple staff rides. He and his counterparts from other agencies choose well documented incidents which allow other firefighters to walk in the foot steps of decision makers and gain an in depth understanding of what led to the ultimate outcome. (emphasis added)

"During a staff ride, participants conduct a preliminary study of an incident, visit the actual site to gain a perspective of the situation that occurred, and then integrate the lessons learned into current operations. When possible, fire managers who worked on the actual incident are present to share the information they had and thinking process at the time that led to specific decisions. Staff rides have been developed and conducted for such well-known fires as Mann Gulch (Montana, 1949), South Canyon (Colorado, 1994), and Cerro Grande (New Mexico, 2000). The integration phase encourages participants to reflect upon those lessons which can be applied to ensure mistakes on these incidents are not made again. (all emphasis added)

"Recently, Wilcox, along with five other FWS fire personnel from the Southwest Region, and a U.S. Forest Service firefighter and a firefighter from Sedona Fire Department led two groups through a staff ride of the Dude Fire (Arizona, 1990), which killed six firefighters. Participants included Bureau of Indian Affairs employees from the Western Region and the U.S. Forest Service Risk Management Council." (all emphasis added)

Wilcox makes a key point regarding the benefit of having those that were actually present on the fires to share their information and thought processes that led to the specific decisions. However, BRHS Supt. Frisby was considered "a distraction" at one of the YH Fire Staff Rides he attended in an After Action Review or on an evaluation form.

Wildland Fire Safety Strategy Meeting Gettysburg, Pennsylvania/ Emmitsburg, Maryland May 2-7, 2016 June 2016 ( http://www.everyonegoeshome.com/wp-content/uploads/sites/2/2016/06/WildlandPaper-FINAL.pdf )

"Very importantly, there seems to be a rising sense among wildland operators and within the leadership of the NFFF that the current fatality rate for wildland responders is unacceptable.

We took unnecessary risk, which was bad war, and the only bad war, I think, too, in all our tactics.” Page 228, Fighting for the Confederacy by Porter Alexander, CSA, in reference to the Battle of Gettysburg."

There are some really good RISK MANAGEMENT DISCUSSION POINTS on this website that you may want to consider.

A haunting anniversary in Yarnell Hill approaches. What have we learned? NFPA Blog Post created by michelesteinberg on May 30, 2018 ( https://community.nfpa.org/community/fire-break/blog/2018/05/30/a-haunting-anniversary-in-yarnell-hill-what-have-we-learned )

"Jeff Whitney, the current Arizona State Forester and State Fire Marshal, impresses me as someone who won't allow the important history of this disaster to be hidden away - that facing it helps all of us learn. NFPA

"Frustration but also resignation with the fact that there are things that we will never know about what actually happened and why certain decisions were made. The leaders repeated to us that they don't know why the crew "left the black" - the safe area where they spent hours that day. I wish I had left that event with more answers. I'm sure many people feel that way. Reviewing the staff ride booklet, I realize that the experience is meant to raise questions, and not necessarily provide answers. I can only hope that those who participate in this and other staff rides ask themselves the hard questions and find ways to prevent future tragedies in the line of duty.

"Take a look at the announcement from the NWCG. There, you will find information about the handful of commemoration events in both Arizona and Colorado, (My colleague, Cathy Prudhomme, also wrote a blog post last Friday about some of these events around the Yarnell Hill Fire. Check out her blog to learn more about what will be happening in Arizona.)

The announcement also provides a number of resources that, according to the NWCG, “will facilitate reflection on, and discussion of, the South Canyon and Yarnell Hill fires as well as some of the hazards that pose the most serious risks to wildland firefighters.”

( https://community.nfpa.org/community/fire-break/blog/2014/06/30/a-week-to-remember-wildfire-community-marks-anniversaries-of-historic-fires )

This blog and all related to the Yarnell Hill Fire is a dead end so far. "Oops, the page can't be found Sorry, the page you requested can't be found. You can go back and try again. (Jun 28)." I sent her an email asking her for what she has.

Source: USFWS Fire Management post. "Refuge Fire Manager a Leading Interagency Trainer - November 2008" ( https://www.fws.gov/fire/news/nm/trainer.shtml )

"To learn from the successes and failures of the past, in particular events which were of national significance to fire policy, and often included firefighter fatalities, the group sponsors “staff rides,” modeled after a military training technique utilized to review past battles. (all emphasis added)

"Wilcox, Fire Management Officer at the Bosque del Apache National Wildlife Refuge in New Mexico, has been involved in the development of multiple staff rides. He and his counterparts from other agencies choose well documented incidents which allow other firefighters to walk in the foot steps of decision makers and gain an in depth understanding of what led to the ultimate outcome. (all emphasis added)

"During a staff ride, participants conduct a preliminary study of an incident, visit the actual site to gain a perspective of the situation that occurred, and then integrate the lessons learned into current operations. When possible, fire managers who worked on the actual incident are present to share the information they had and thinking process at the time that led to specific decisions. Staff rides have been developed and conducted for such well-known fires as Mann Gulch (Montana, 1949), South Canyon (Colorado, 1994), and Cerro Grande (New Mexico, 2000). The integration phase encourages participants to reflect upon those lessons which can be applied to ensure mistakes on these incidents are not made again. (all emphasis added)

"Recently, Wilcox, along with five other FWS fire personnel from the Southwest Region, and a U.S. Forest Service firefighter and a firefighter from Sedona Fire Department led two groups through a staff ride of the Dude Fire (Arizona, 1990), which killed six firefighters. Participants included Bureau of Indian Affairs employees from the Western Region and the U.S. Forest Service Risk Management Council."

Wilcox has made a valid point here: "When possible, fire managers who worked on the actual incident are present to share the information they had and thinking process at the time that led to specific decisions." However, BRHS Supt. Frisby was considered "a distraction" on one of the YH Fire Staff Rides he attended based on comments made during an After Action Review (AAR) or evaluation form.

There is also the fact that there still are two Eyewitness Hikers that were on the Weavers that weekend June 28-30, 2013, who offered to help develop and participate in the YH Fire Staff Ride and have been declined and denied even to be able to attend one of their staff rides and was told nowadays they do it all through a NWCG / Lessons Learned and their committee for a nomination process. Yet I was able to get on the Little Venus Staff Ride this year without any nomination process or hassles.

Source: ( https://www.frames.gov/catalog/15805 )

South Canyon Staff Ride online ( https://www.southcanyonfire.com/south-canyon-staff-ride )

Staff rides push past the basic question of “What happened?” to deeper questions of leadership and decision making. Each year, firefighters and managers participate in a staff ride for the South Canyon Fire. The materials for this staff ride are presented online here, and provide a great deal of information about the South Canyon Fire.

NASF Wildland Fire Committee chairman Jim Karels June 14, 2019 ( https://www.stateforesters.org/2019/06/14/nasf-wildland-fire-committee-meets-in-rural-washington-state/ )

The NASF Wildland Fire Committee, chaired by Florida State Forester Jim Karels and staffed by NASF Fire Director Dan Smith, met May 29-30, 2019 in Winthrop, Washington, to discuss pressing national wildfire concerns including cooperative fire agreements, interstate forest fire compacts liability legislation, the concept of shared stewardship, funding for the State Fire Assistance and Volunteer Fire Assistance programs, and implementation of wildland fire technology. (all emphasis added)

Special meeting guests included Shawna Legarza, director of fire and aviation for the USDA Forest Service, Rich Elliott, member of the International Association of Fire Chiefs’ Wildland Fire Policy Committee, and Jeff Rupert, director of wildland fire for the Department of Interior. Representatives from FEMA also provided meeting goers with updates on the development of FEMA Supplemental Response Teams and information on how state forestry agencies can support that effort and participate in FEMA’s wildfire mitigation grant program. (all emphasis added)

The meeting closed with a half-day field tour led by the Washington Department of Natural Resources and Washington State Forester George Geissler. Attendees visited the Thirtymile Fire (2001) and the Twisp River Fire (2015) sites and heard from several first responders who provided initial response on the fires. Today, first responders promote lessons learned through staff rides at both sites.

(all emphasis added)

Have questions? Contact Communications Director Whitney Forman-Cook at wforman-cook@stateforesters.org.

Wildfire Expert Alleges Arizona Forestry Division Covering Up Yarnell Hill Tragedy

John Dougherty | April 5, 2016

"I think the staff ride is an insult to all of [the Hotshots'] loved ones because [materials associated with it don't tell] the truth," said Ted Putnam, a retired wildfire fatality investigator and Chino Valley resident who has conducted an unofficial probe of the Yarnell Hill Fire. "The biggest tribute we should do for these firefighters is to tell the truth." Putnam was provided a copy of the facilitator guide to be used during the staff ride by New Times, which obtained it from the state Forestry Division through an Arizona Public Records Law request. Putnam contended he has direct information from multiple firefighter sources who were at the fire in conjunction with evidence contained in investigation reports that leave no doubt that the state Forestry Division ordered the Granite Mountain Hotshots to come off the mountain and go to Yarnell. “I've been in this business longer and know more about this than anybody out there, and this all this screams at me they were ordered off the top [of the mountain],” Putnam said. Putnam, a former "smoke jumper," served as an investigator on high-profile fatal wildfires including the 1990 Dude Fire in Arizona and the 1994 South Canyon Fire in Colorado. Putnam is considered a leading expert in wild-land fire entrapment and has been cited as a pioneer in advancing scientific knowledge on the subject. He gained notoriety when he refused to sign the official accident investigation report for the South Canyon Fire, where 14 hotshots and smoke jumpers were killed, because he believed the report was untrue." (all emphasis added)

( https://www.phoenixnewtimes.com/news/wildfire-expert-alleges-arizona-forestry-division-covering-up-yarnell-hill-tragedy-8186962 )

Putnam said the [SAIT-SAIR] report's conclusion defies logic. He does not believe that Granite Mountain Hotshots Superintendent Eric Marsh would have ordered his men to leave their safe zone unless he was pressured by superiors to get the crew to the town of Yarnell. At the time the crew moved off the mountain, the fire was sweeping into Yarnell, forcing many residents to evacuate. “Marsh's action makes no sense at all unless he was ordered off the top,” Putnam said. (all emphasis added)

He said he cannot reveal his sources because they provided the information under the promise of confidentiality. But he says he will provide complete details in a formal setting under oath. It sounds like it's about time to sue some of these YH Fire IMT and WF and FF personnel and YH Fire SAIT members into Federal Court to get Dr. Putnam to reveal his promised confidential information.

The Human Element: Revisiting the Lessons of the Esperanza Fire

The decision to engage in structure protection or interior fire operations needs to be based on available facts, not emotion.

Timothy E. Sendelbach

October 19, 2015

( https://www.firehouse.com/safety-health/article/12127755/nfff-new-goals-firefighter-safety-in-the-wildland-interface-esperanza-fire )

What follows are a series of photos from June 30, 2013, in more or less, chronological order. Many times are approximated, (i.e. mid- to late morning, etc.)

Figure 2. Fire on Parcel APN: 800-20-045U/ 800-20-047S Arizona State Land. Peeples Valley area Fire Behavior on June 30, 2013 appx. 9:14am, after we, 2 hikers, left the GMHS Div A/Mystery Man on top of the Weavers - Old Grader site in lower right black oval. Source: Joy A. Collura

At this point the Granite Mountain Hotshots (GMHS) already passed us in Figure 1. but the next photo is one of the photos ( Figure 3. ) of the GMHS hiking up the 2-Track Ridge on June 30, 2013, a few minutes before the "timestamped" passing of the Yarnell Hill Fire ( YH Fire ) eyewitness at 9:18 AM.

We originally saw the GMHS hiking out past the "Old Grader" area except GMHS (Div A) Eric Shane Marsh was separate and away from the men; and by using Google Earth ruler I measured the distance of approx. 1.06 miles that DIV A was separate from the Crew scouting and tying pink tape to bushes (i.e. Wildland Terminology- flagging) that morning until his crew met Div A on the Weaver Mountain 2-track ridge "lunch spot" area.

The very first sighting the Hikers saw Div A was at GPS coordinates 34°13'34.55"N 112°46'59.46"W in a drainage near a boulder, which I reported to Holly Neill on our November 2013 hike. This drainage, if followed, goes right to the Sesame area as well to the Pumpkin - Boulder Springs Ranch (BSR) and that was at 8:04 AM. And within five minutes DIV A walked up to us the Hikers by 8:09 AM. That was right when you begin to hike up the 2 track ridge from the base - quarter way up.

Figure 2. Granite Mountain Hotshots hiking cross-slope, cross country through the brush (bottom right) up toward their eventual Lunch Spot in the Weaver Mountains on June 30, 2013, approx. 0915 hours (9:15 AM). The 2-Track Ridge road is in the left background. Source: Joy A. Collura

On every wildland fire anniversary, usually in the NWCG “6-Minutes For Safety” postings, this admonition is published: “This Day in History is a brief summary of a powerful learning opportunity and is not intended to second guess or be judgmental of decisions and actions. Put yourself in the following situation as if you do not know what the outcome will be. What are the conditions? What are you thinking? What are YOU doing?” (emphasis added) (https://www.nwcg.gov/committees/6-Minutes-for-safety) So then, why is it that we are not allowed to benefit from such a powerful learning opportunity when we are forbidden to "second guess or be judgmental of decisions and actions" that were very likely causal factors responsible for their deaths?

This clearly follows the 2002 Saddlebrook Fatality Learning Review "decisions and actions" logic and thought process by alleged "Lead YH Fire Investigator" Brad Mayhew particularized in this post:

( https://www.investigativemedia.com/please-begin-yarnell-hill-fire-chapter-xxvii-here/#comment-479163 )

Figure 3. Snippet of three GMHS in the brush with red hardhat on left and outstretched arm on the right at 10:36am. NIKON D80 photos. _6696.JPG Source: Filename "Deertrack Drive" photo collection of local anonymous resident.

Figure 3 and Figure 4 are proof that we need everyone's photos and videos so we can pixel through to properly time stamp when the GMHS were up on the Weavers and where the vehicles were on June 30, 2013. There were others that took picture(s) of the men

That 'private/unlisted' video link of three GMHS firing out in the brush is as follows:

( https://youtu.be/b3KShvWbbl8 ):

Figure 4. Video of three GMHS in the brush on June 30, 2013, at 10:36am. NIKON D80 photos. _6696.JPG Source: YOUTUBE (WTKTT) - Filename "Deertrack Drive" photo collection of local anonymous resident.

As it turns out, one of the photos from that "Deertrack Drive" collection (from which the video above originated) contains a photo which actually SHOWS three of the Granite Mountain Hotshots ( including, apparently, Jesse Steed with his RED helmet ) on the two track ridge in same area the Yarnell Hill Fire Eyewitness took the photos of the men when we were up on that 2-track ridge on June 30, 2013, as shown in the photo below in Figure 5.

Figure 5. June 30, 2013, mid- to late-morning photo of the Granite Mountain Hotshots "at ease" and not at work contrary to what was reported by the Daily Courier. Source: Joy A. Collura

Figure 6. June 30, 2013, mid- to late-morning photo of the Granite Mountain Hotshots "at ease" and not at work contrary to what was reported by the Daily Courier. Some with sleeves rolled up with nearby fire behavior to the right. Source: Joy A. Collura

Figure 7. June 30, 2013, mid- to late-morning photo of the Granite Mountain Hotshots "at ease" and not at work contrary to what was reported by the Daily Courier Source: Joy A. Collura

These men during this phase of the fire in this photo were NOT engaged in doing "work" or creating a fire break. That ridge has been like it is shown since the late 1960's. I watched the one hotshot use his Wildland tool to "toss rocks".

The Daily Courier did not report my photograph accurately, especially on the photo above, as they wrote the men were doing work. It has since been removed and you can go to Wildfire Today link to confirm:

Figure 8. Snippet of Wildfire Today article (July 21, 2013) (https://wildfiretoday.com/2013/07/21/hikers-photos-of-granite-mountain-19-before-the-tragedy/) Source: Wildfire Today

So then, if you are new to this blog or to InvestigativeMEDIA or the Yarnell Hill Fire and are just now learning about this, here are some quick recap photos to share that should be developed into the making of the Yarnell Hill Fire Staff Ride as viable "Information Sources."

Figure 9. Fuel, terrain, and fire behavior with a June 30th SEAT retardant drop (red) in the process of actually making a retardant drop in the brush on June 30th, 2013, approx late morning. Source: Joy A. Collura

Figure 10. Fuel, terrain, and fire behavior with a prior June 29th SEAT retardant drop (red) evident in the brush on June 30th, 2013, approx. mid- to late morning. GMHS barely visible in upper left corner of photo. Source: Joy A. Collura

Figure 11. Fuel, terrain, and fire behavior on June 30, 2013, approx. 9:00 AM. Source: Joy A. Collura

Figure 12. Fuel, terrain, and fire behavior we saw when we arrived in the area on June 30th, 2013, approx. 8:45 AM. This is in the area that AA Rory Collins used SEATS to extinguish the GMHS's burnout Source: Joy A. Collura

Figure 13. Fuel, terrain, and fire behavior on June 30, 2013, approx. 8:45 AM. Mid-slope road evident diagonally in lower left. Source: Joy A. Collura

Figure 14. Fuel, terrain, and fire behavior on June 30, 2013, approx. 7:45 AM to 8:00 AM taken from drainage area where we first saw DIVS A that morning. Source: Joy A. Collura

Figure 15. Fuel, terrain, and fire behavior on June 30, 2013, approx. mid- to late morning. GMHS with black hardhat at black arrow in mid-lower left photo. Source: Joy A. Collura

Figure 16. Fuel, terrain, and fire behavior on June 30, 2013, morning time. Old Grader site mid-photo (black oval) and mid-slope road lower mid-photo (black arrow). Airborne retardant drop underneath down pointed arrows left photo Source: Joy A. Collura

Figure 17. Fire Vehicles driving back and forth on the Sesame/Shrine Trail areas on June 30, 2013, approx. mid-morning Source: Joy A. Collura

I took this photo because Tex Gilligan saw all the aircraft hovering and some too low hovering and bulldozers making trails in dense brush areas with vehicles following the bulldozer (dozer). Gilligan told me that 'this fire is now being turned into a controlled burn and no human lives should be out here and we needed to get the hell out of there.'

Figure 18. BRHS Crew Carrier among the fire vehicles driving back and forth on the Sesame/Shrine Trail areas on June 30, 2013, approx. mid-morning. Source: Joy A. Collura

Figure 19. BRHS Crew Carrier among the fire vehicles driving back and forth on the Sesame/Shrine Trail areas on June 30, 2013, approx. mid-morning. Source: Joy A. Collura

Figure 20. Dozer building fireline (dozer line) along the Sesame/Shrine Trail areas on June 30, 2013, approx. mid-morning. Source: Joy A. Collura

Figure 21. Dozer building fireline, BRHS Supt. truck, and fire vehicle traveling back and forth on the Sesame/Shrine Trail areas on June 30, 2013, approx. mid-morning. Source: Joy A. Collura

Figure 22. Dozer constructing fireline and fire vehicles traveling back and forth on the Sesame/Shrine Trail areas on June 30, 2013, approx. mid-morning to late morning. Source: Joy A. Collura

Figure 23. Fuel, terrain, and fire behavior in the Harper Canyon area on June 30, 2013, approx. 1:00 PM with saddle just below and BSR below right. Source: Joy A. Collura

Figure 24. Fuel, terrain, and fire behavior along the Harper Canyon area on June 30, 2013, approx. 1:00 PM. Source: Joy A. Collura

Figure 25. Fuel, terrain, and fire behavior along the Harper Canyon / Sesame / Shrine Trail areas on June 30, 2013, approx. 1:00 PM. Source: Joy A. Collura

Figure 26. Fuel, terrain, and fire behavior along the Harper Canyon, Sesame/Shrine Trail areas on June 30, 2013, approx. 1:00 PM. Source: Joy A. Collura

Figure 27. Fuel, terrain, and fire behavior we eye-witnessed on June 30, 2013 approx. 1:11 PM. Harper Canyon mid-photo and 2-track ridge road along left photo. BSR and GMHS DZ toward the right. Source: Joy A. Collura

Figure 28. Fuel, terrain, and fire behavior looking toward the Old Grader area that we eye-witnessed on June 30, 2013, approx. 1:11 PM with BSR Crew Carrier n mid-right photo. Source: Joy A. Collura

Figure 29. Fuel, terrain, and fire behavior that we eye-witnessed on June 30, 2013, approx. 1:11 PM along the Sesame/Shrine Trail areas. Old Grader site at faint black arrow mid-lower bottom. Source: Joy A. Collura

Figure 30. Fuel, terrain, and aggressive fire behavior we eye-witnessed on June 30, 2013, approx. 1:11 PM along the Harper Canyon area. Source: Joy A. Collura

Figure 31. Fuel, terrain, and aggressive fire behavior we eye-witnessed on June 30, 2013, approx. 1:11 PM along the Sesame/Shrine Trail areas. Source: Joy A. Collura

Figure 32. Fuel, terrain, and aggressive fire behavior we eye-witnessed on June 30, 2013, approx. 1:11 PM along the Sesame/Shrine Trail areas. Source: Joy A. Collura

Figure 33. Fuel, terrain, and aggressive fire behavior we eye-witnessed on June 30, 2013, approx. 1:11 PM along the Sesame/Shrine Trail areas. Source: Joy A. Collura

Figure 34. DPS helicopter on June 30, 2013 Source: Joy A. Collura

Figure 35. Fuel, terrain, and increasing fire behavior we eye-witnessed on June 30, 2013, approx. 1:11 PM past the Old Grader to the left at the base of the Weavers. Source: Joy A. Collura

Figure 36. Fuel, terrain, and fire behavior we eye-witnessed on June 30, 2013, approx. 1:11 PM along the Sesame/Shrine Trail areas. Source: Joy A. Collura

Figure 37. GMHS Crew Carriers in small clearing on June 30, 2013,. Source: Joy A. Collura

Figure 38. Fuel, terrain, and increasing fire behavior with associated dark smoke column that we eye-witnessed on June 30, 2013, approx. 1:11 PM along Harper Canyon area and the Sesame/Shrine Trail areas. Source: Joy A. Collura

Figure 39. Fuel, terrain, and increasing fire behavior that we eye-witnessed on June 30, 2013, approx. 1:11 PM along the Sesame/Shrine Trail areas. Source: Joy A. Collura

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Consider now a series of links and some quotes from a "fifth season" USFS WF with the website blog titled "Student of Fire" with a blog post titled: "About Student of Fire."

"About Student of Fire

"The idea for this website came from my growing enthusiasm for seeking out wisdom anywhere it could be found. This is my fifth season in fire and it seemed a good way for generating ideas and pursuing them further. But going from firefighter to student of fire, I owe that to Paul Gleason among others." (all emphasis added)

"During a recent 2800-mile road trip to the southwest, I made a site visit to the 1990 Dude Fire and attended a staff ride in Arcadia California for the Loop Fire of 1966. While revisiting the documents tied to those incidents – things like investigation reports, newspaper articles, old photographs and maps – one thing became ingrained in me. It was a speech Paul Gleason made in 1996 ... honoring those killed 30 years earlier in the Loop Fire. “Unfortunately, much of our knowledge and lessons learned about wildland fire have been gained only through the high cost of firefighters’ lives.” (all emphasis added)

I think the SoF author then closes that post with this statement ostensibly from Paul Gleason: "He goes on to say that to honor them, we must learn what we can in order to prevent unnecessary repeats; we must be, students of fire." (emphasis added) ( http://studentoffire.org/index.php/sample-page/ ) Here's his Facebook link: ( https://www.facebook.com/Studentoffire/ )

The Student of Fire aptly noted that "It takes a lot of courage to stand up to the status quo, to the way things have always been, and say I think we can do better, I think we should demand more from ourselves." He was in some sort of Agency meeting about the upcoming new outlook on fire management and this is what he said: "I got to see that today, in person. A room full of people voicing their opinions, thoughts, and doubts about a vision for the future, about their role in it, and how it would all play out. Today I witnessed some serious leadership at work and it was awesome." (all emphasis added)

Please spend the time and read this guy's posts and commentary.

He seems like a very bright fellow who loves Wildland Firefighting with the same fervor that many do, but he, himself, has looked at the evidence and coins an interesting phrase relevant to the YH Fire - "Marsh's Death March" in the post below titled: On the Road: Yarnell posted January 18, 2017

We want to apply what he experienced and felt as well as his sense of awe and enthusiasm to what we are accomplishing here about true, complete lessons learned that share the truth about what occurred on the fatality wildland fires incorporated into meaningful Staff Rides in order to better analyze their decison-making at the time.

Yarnell Hill and Granite Mountain Hotshots: Books and Thoughts

July 2, 2016 by studentoffire

( http://studentoffire.org/index.php/2016/07/02/revisiting-yarnell-thru-some-granite-mountain-literature/#respond )

SoF admits to being starved for information on the YH Fire and so, almost all these YH Fire and GMHS books are the from among the ubiquitous "Party Liners," adhering ever-so-strictly to the SAIT-SAIR, without basing their writing on facts and / or factual events that they know, but will not admit, exist.

On The Road: Yarnell

January 18, 2017 by studentoffire 19 Comments

Is it merely a coincidence or something else that would have this end with "19 comments?"

( http://studentoffire.org/index.php/2017/01/18/on-the-road-yarnell/ )

“'Why did Granite Mountain leave a good safety zone?' This failure gets right to the heart of how the majority of us approach this event, which holds some pitfalls. It implies that until we find the answer to that question, we don’t have enough information to learn anything of value." (all emphasis added)

Exactly, hence the "incomplete" lessons learned referred to by researcher and author Diane Vaughan regarding the Normalization of Deviance here cited in a NASA training module titled: The Cost of Silence: Normalization of Deviance and Groupthink from a November 3, 2014, Senior Management Meeting (check out their references).

( https://sma.nasa.gov/docs/default-source/safety-messages/safetymessage-normalizationofdeviance-2014-11-03b.pdf?sfvrsn=c5421ef8_4 )

"What I’d really like is for there to be another fire order or watch out situation. Something a bunch of overpaid stiffs decided was a critical element in the tragedy of Yarnell, something I could tell younger guys about, as a tip, a lesson learned. (emphasis added)

There need be no more Fire Orders or Watch Outs added because of the blunders by the GMHS on the YH Fire. They were already in place and merely ignored and certainly not followed by the GMHS, resulting in the mass fatality.

"This fire was my generations Storm King. This was a big fucking deal. (all emphasis added)

This is almost verbatim what we hear from most young WFs and FFs these days about the YH Fire being the classic modern example of a fatality fire.

"I put in a chew and sat on a bench and wondered why the hell they decided to make that mad dash, to go on Marsh’s death march. Nobody knows." (all emphasis added)

This is another classic emotional conclusion felt by WFs and FFs (Matt) familiar with the YH Fire and the GMHS; for those that were actually there and certainly for those that examine it and study it desperately searching for true, complete lessons learned. Unfortunately, all these WFs and FFs really get are "incomplete" lessons learned. Vaughan (2005) System Effects: On Slippery Slopes, Repeating Negative Patterns, and Learning From Mistake? ( http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.456.5317&rep=rep1&type=pdf )

Another SoF post titled: Preparing For A Staff Ride That Doesn’t Involve Fire

January 18, 2018 by studentoffire

Two commenters below:

Brad Hardesty

January 18, 2018 at 1:38 am

I participated in the Shiloh Staff rode last year and took so much away from it. There are so many common factors in-between the two. You can see so many common factors between our 10 and 18s and battle. This is a great staff ride and each participate can gain so much from it

Reply

  • studentoffire

January 18, 2018 at 11:42 am

The ten and 18…very cool yeah I can definitely see that. Now you made more work for me. Thanks.

"Matt [a commenter - the last one for the "On the road: Yarnell" post]

January 27, 2017 at 7:55 pm

"It is unquestionably a tragedy that 19 men in the prime of their lives were cut down by fire. It is completely understandable that the survivors of those men do everything they can to honor their memories. It is unforgivable that we allow sentiment and tradition prevent us from learning anything from the human factors surrounding Yarnell because we continue to be blinkered and sentimental in our eagerness to “not speak ill” of the dead. It is nothing short of astonishing that the official conclusion was that everybody involved in the Yarnell Hill Fire did everything right – despite the incineration of the 19 hotshots by flames so hellish that granite boulders fractured. Covering up facts because they make us uncomfortable dishonors the dead, and ensures the same mistakes will be made in the future." (all emphasis added)

Elsewhere on the SoF website: "Honoring those who have fallen by learning as much as we can to prevent similar tragic events in the future doesn’t necessarily entail having information that doesn’t exist. We want to revisit the Yarnell Hill tragedy and see a specific decision or turning point, where we can neatly say “there, that’s where they screwed up; that’s why they were killed”, or, “that’s why they did what they did”. (all emphasis added)

"Maybe we don’t have an updated LCES, a new set of firefighting orders or watch out situations because of Yarnell Hill. But Yarnel [sic] Hill happened. Maybe that’s the most important thing to remember: sometimes the lesson we want to learn isn’t necessarily the lesson being afforded us. I find this to be true, time and time again, in my perpetual pursuits of knowledge and the never-ending study of Fire." (all emphasis added)

The GMHS had LCES, however, they failed to properly apply LCES as it was designed. They had the best view of the entire fire, save Air Attack, so the "L" prong is covered. They had communications, however, failed to properly apply the "C" prong by talking mostly on their discreet Crew Net, The properly applied he "E" prong by using an Escape Route to go from their perceived danger to the black and their "Lunch Spot." This is the common definition and use of the "E" prong of LCES, a route FROM danger to safety. NOT from safety into danger which is what they did.

The GMHS completely perverted the meaning and use of the term "Escape Route" and turned it on it's head. The SAIT-SAIR basically ignored honestly dealing with this issue and addressing the fact that the GMHS were deceptive, among other things.

DIVS A says, “I want to pass on that we’re going to make our way to our escape route.” (p. 24) (all emphasis added)

The GMHS had already utilized their Escape Route to their Safety Zone, so they are being deceptive with Air Attack instead of informing them they were leaving their Safety Zone.

"Following this conversation, ASM2 hears DIVS A announce on the radio, “We’re going down our escape route to our safety zone.” ASM2 asks, “Is everything okay?” to which DIVS A replies, “Yes, we’re just moving.” (p. 27) (all emphasis added)

Once again, the GMHS had already utilized their Escape Route to their Safety Zone, so they are being deceptive with Air Attack instead of informing them they were leaving their Safety Zone.

"DIVS A (now more urgent): “Yeah, I’m here with Granite Mountain Hotshots, our escape route has been cut off. ...” (p. 28) (all emphasis added)

Once again, the GMHS had already utilized their Escape Route to their Safety Zone, so they are being deceptive with Air Attack instead of informing them they were leaving their Safety Zone.

Consider now the excerpts from the SAIT-SAIR on Escape Routes with occasional references to Safety Zones with it being rather odd that they would address Safety Zones BEFORE Escape Routs.

The SAIT-SAIR Course of Action A-4: "They perceived this southeast pathway as an escape route. • If they take this route, it appeared they would still have alternate escape routes southwest over the ridge or back to the black the way they came." (all emphasis added)

They did much more than perceive this southeast pathway as an escape route because they utilized it as one as well. (all emphasis added)

"Course of Action B2 on p. 39: "Could keep open the option to move over the ridge, southwest toward Highway 89 allowing for a secondary escape route." (all emphasis added)

In the Safety Zone section the SAIT-SAIR talks of Escape Routes: "In terms of collective sensemaking and inquiry, one aspect of the crew’s communication stands out. The crew communicated that they were moving along their escape route to a safety zone, yet others on the fire believed their location was in a safety zone (the black). Personnel in a safety zone do not need an escape route. Others on the fire inquired with the Granite Mountain IHC about their status and location, yet that inquiry did not lead to mutually accurate understanding." (p. 51) (all emphasis added)

"One communication exchange illustrates how inquiry might lead to collective reassessment. At about 1600 after hearing about “a crew in a safety zone,” the ASM asked if they needed to call a time out.

Operations replied that it was the Granite Mountain IHC and that they were safe. Then, sometime later, DIVS A followed up and said they were traveling along their escape route to a safety zone. The ASM’s question about pausing operations is a good example of one resource updating situational awareness about another resource’s location and relative safety, and even recommending an action that could have helped update everyone’s collective sense of the crew’s status and location. ... may have led many on the fire to mentally file the crew back in the “safe” category." (p. 51) (all emphasis added)

Escape Routes is finally covered AFTER Safety Zones on p. 52!

"Escape Routes

"Continuing from this previous point, the Yarnell Hill Fire also prompts us to think about the connections that firefighters make between escape routes and safety zones. As noted above, we believe the Granite Mountain IHC did not perceive their route as overly risky, or they would not have taken it. Wildland firefighters should consider to what extent a strong vote of confidence about the effectiveness of a safety zone might be interpreted as a strong vote of confidence about potential escape routes for getting there. Conversely, is there some implied measure of the safety along an escape route. (p. 52) (all emphasis added)

The SAIT makes a huge leap here with this statement: "did not perceive their route as overly risky, or they would not have taken it." (all emphasis added) This actually belies the history of the GMHS and their steady drift into failure with their recurring Bad Decisions With Good Outcomes on many other fires.

"One might view traveling through an escape route to a safety zone as making educated guesses as to the route and anticipated travel speed while running to a specific point. The educated guess is that the crew can reach the safety zone before the fire reaches them. There are many variables involved in this equation but perhaps the most important one is speed. If the fire can travel at a faster rate than the firefighters, they will lose the race. If they can travel faster than the fire, they will win the race. In order for the educated guess to prove out, the firefighters must predict three things with some degree of accuracy: how fast the fire will travel, which direction the fire will travel, and how fast they will travel. It is possible to misestimate all these factors and suffer no consequences, for example if the firefighters misestimate the fire’s direction of travel but it moves away from their position. However, misestimating any of these variables could cause serious trouble and firefighters misestimating them all may pay the ultimate price." (p. 53) (all emphasis added)

The SAIT once again takes liberties on this conclusion as well: "One might view traveling through an escape route to a safety zone as making educated guesses as to the route and anticipated travel speed while running to a specific point. The educated guess is that the crew can reach the safety zone before the fire reaches them." (all emphasis added)

Where does our WF training talk about an taking or using an "educated guess" dealing with LCES and Escape Routes in particular? No where. It doesn't. The SAIT seems like they are trying their best to justify the GMHS perverted and unsafe thought process and let other WFs and FFs know that this is completely acceptable.

How does one travel "THROUGH an escape route"? And the GMHS obviously "misestimat[ed] them all and paid the ultimate price." (all emphasis added)

"Wildland firefighters often discuss the need to have multiple safety zones; many firefighters also identify multiple escape routes to the same safety zone, if they exist, although this can require extensive scouting. In hindsight, we know that the Granite Mountain IHC might have arrived at the Boulder Springs Ranch if they had stayed on the two-track road, although it is unclear whether the crew knew that, or how long it might have taken to get there. This highlights another problem posed by limited mobility: because the Granite Mountain IHC was on foot, their ability to scout potential escape routes was limited. Lookouts Lookouts, Communications, Escape Routes, and Safety Zones (LCES) is an interconnected system approach to fireline safety, so it is difficult to discuss safety zones and escape routes without also addressing lookouts. The Granite Mountain IHC had a designated lookout for most of the day, until the advancing fire threatened the lookout’s location and forced him to withdraw. This points to one paradox of firefighting: Crews post lookouts to increase safety, but there is no guarantee of the lookout’s own safety. The Granite Mountain IHC never took explicit action to replace this lookout after he was forced to withdraw, but it is likely that DIVS A was serving as a lookout for the crew and that the crew was also exercising their own vigilance. In all the photos of the crew at the lunch spot, they appear focused on the active fire." (p. 53) (all emphasis added)

The SAIT begs the question here with the Logical Fallacy of Circular Reasoning. "This highlights another problem posed by limited mobility: because the [GMHS] ... ability to scout potential escape routes was limited." (all emphasis added)

"This fallacy is committed when a person merely assumes what he is attempting to prove, or when the premise of an argument actually depends upon its conclusion." The Fallacy of Begging the Question by Dr. Jason Lisle on August 17, 2009 ( https://answersingenesis.org/logic/the-fallacy-of-begging-the-question/ )

Limited mobility limited their ability to scout for other escape routes. The bottom line is you cannot assume what you are trying to prove.

"Whether the crew recognized it or not, their decision to go down the hillside from the Descent Point was a decision to sacrifice some of their effectiveness in serving as their own lookouts. Taking a more direct escape route to minimize exposure in the green generally means traveling a shorter distance and potentially reaching the safety zone more quickly. Moving down the slope into the box canyon meant the Granite Mountain IHC would no longer be able to see the fire. We wondered: Is it possible that they relied on the rock outcropping as a barrier to fire spread? But is it also possible that the outcropping blocked their view of the fire? We will never know if the crew understood that this route of travel required that they sacrifice some of their capacity to serve as their own lookouts. We will also never know if they understood the calculated risk involved in traversing the final distance to the Ranch without the level of situational awareness that a different vantage point might have afforded." (p. 54)

The SAIT has played into and somewhat accepted the GMHS perversion of the term "escape route" term after the fact of them already successfully using one to safely reach their Safety Zone in the black.

However, the GMHS then perverted that "E" prong of LCES throughout their radio conversations with overhead (OPS) and adjoining forces (BRHS) by talking about their "predetermined route" after they surreptitiously left the black until they then announced that they were "ahead of the flaming front" and that their "escape route had been cut off" and that they would be deploying fire shelters.

"With the help of our SMEs, we developed the following questions for discussion by various fire resources regarding fireline safety." (p. 54) (all emphasis added)

"Some Questions for Ground Crews and Aviation Resources

• When others point out a safety zone to you, what questions do you ask about how they assessed the viability of the site and the safety of the route(s) for getting there? (all emphasis added)

Since all escape routes are necessarily “through the green” or through black that is not very “good,” what characteristics make one escape route better than another? (all emphasis added)

The SAIT once again takes some liberties here with this statement above.

When you identify an escape route, do you also discuss trigger conditions that would prompt reassessment?" (p. 54) (all emphasis added)

"~1641:30 Division A tells Air Attack their escape route has been cut off and they’re deploying shelters. ASM2 asks if they are on the south end of the fire. Division A says “Affirm!” (p. 64) (all emphasis added)

"Appendix D: Aviation Summary

"At approximately 1615, ASM2 heard radio traffic between Division Supervisor A (DIVS A, which included Granite Mountain Hotshots) and Operations about Granite Mountain going down their escape route to a safety zone." (p. 100) (all emphasis added)

"The Investigation Process

"Approach and Philosophy

"The primary goal of this report is to facilitate learning from this tragedy, in order to reduce the likelihood of future accidents. To this end, the Team retained some of the most effective techniques of past investigations while integrating current theory and practices. ... This report does not identify causes in the traditional sense of pointing out errors, mistakes, and violations but approaches the accident from the perspective that risk is inherent in firefighting. Leaders are responsible for guiding firefighters in consideration of the tradeoffs between safety, risk management, and other organizational goals. In this report, the Team tries to minimize the common human trait of hindsight bias, which is often associated with traditional accident reviews and investigations. The Team based its approach on the philosophy that firefighters are expected and empowered to be resourceful and decisive, to exercise initiative and accept responsibility, and to use their training, experience and judgment in their decision-making. The wildland fire community uses a doctrine approach to fire suppression, which requires the use of judgment. An individual’s judgment in a given situation depends upon their unique training and experiences. The 10 Standard Firefighting Orders and 18 Watch Out Situations (10 and 18) are the foundation of training in fire suppression operations, but they require judgment in application. These principles, as stated below, outline the Team’s perspective regarding the use and consideration of the 10 and 18 in this report: (all emphasis added)

To this end, the Team retained some of the most effective techniques of past investigations while integrating current theory and practices.

"Principles of Suppression Operations

“The primary means by which we implement command decisions and maintain unity of action is through the use of common principles of suppression operations. These principles guide our fundamental fire suppression practices, behaviors, and customs, and are mutually understood at every level of command. They include Risk Management, Standard Firefighting Orders and Watch Out Situations, LCES [Lookouts, Communications, Escape Routes, and Safety Zones], and the Downhill Line Construction Checklist. These principles are fundamental to how we perform fire suppression operations and are intended to improve decision making and firefighter safety. They are not absolute rules. They require judgment in application.” In light of this doctrine, the Team attempted to use foresight rather than hindsight in this discussion. That is, the Team tried to stand with the crew to try to understand, as best they could, what crewmembers were seeing and how they were making sense of unfolding conditions, when it was time to act . The Team also looked at broader cultural factors that may have influenced the crew. This helps set the stage for ongoing learning, which began with the Team’s efforts and which will continue over time in the greater wildland fire community. (p. 5) (all emphasis added)

They are not absolute rules. They require judgment in application. (all emphasis added)

" ... broader cultural factors that may have influenced the crew. This helps set the stage for ongoing learning, which began with the Team’s efforts and which will continue over time in the greater wildland fire community."

On the contrary, the Fire Orders ARE indeed "absolute rules" even though they require judgement in application.

Wildland Firefighter Safety Awareness Study Phase I - Identifying the Organizational Culture, Leadership, Human Factors, and Other Issues Impacting Firefighter Safety - October 1996

( https://www.nifc.gov/safety/safety_documents/phase1.pdf )

This is also known as the Tri-Data Study and LOTS of good information, including the FF and Manager quotes in Appendix B. A total of 243 pages.

Open Letter on the Cramer Fire Anniversary written by Kelly Close, FBAN re-printed by permission of the author ( http://www.coloradofirecamp.com/Cramer/letter.htm )

Well worth checking out this entire Cramer Fire link for the valuable insights you will receive from this historical wildland fire tragedy and more.

WF Quotes from "The Big Lie in Wildland Firefighting" by Mark Smith

( http://www.mkrfa.com/uploads/pdf/Macs-Folder/The%20Big%20Lie%20in%20Wildland%20Fire%20Fighting%20MSmith%202015.pdf )

“One of the few acts of free will that tragedy leaves within our control is the chance to grow. Our brothers have given us such a precious and hard won opportunity to learn new knowledge and apply lessons. We realize and seek to highlight that cultural and other human factors risks are just as profound and potentially deadly as physical risks on any incident. (all emphasis added)

"The results WILL be repeated unchecked unless we commit to looking inside, to looking deeper at how we think, how we talk and how we perceive ourselves." (all emphasis added)

"Our end state is that the group’s efforts became a catalyst for continued cultural introspection into how human factors affect our decisions. The engagement generates a watershed event from the fire, having provoked thought, dialogue, questions and explorations in all corners of the wildland fire community. Yarnell Hill leads to a stronger, more self‐aware and more resilient wildland fire culture.

(all emphasis added)

"Our effort was perceived as having rendered due honour and respect to the Granite Mountain Hotshots.

It seems rather odd that they would give the deceased members of the GMHS "brother" credit for "such a precious and hard won opportunity to learn new knowledge and apply lessons" as if they did this intentionally.

Now to address our original question: "Were Wildland Fire Fatality Staff Rides, based on revisiting Military Battlefields, designed to be a unique method to convey the "complete" wildland fire lessons learned of the past to the present day Wildland Fire Leaders?"

Simple answer, right? Yes, of course there is assuming that the truth is told and complete lessons learned are garnered from it and carried forward to all future generations of WFs and FFs.

Consider now a quote from a historical fiction TV movie series titled Turn. It is set during the Revolutionary War delving into the Culper spy ring, a network that, at various times throughout the war, provided extremely valuable intelligence to the Continental Army, often at a heavy price. The author's comments on contradiction follow the quote.

The revolution never ends. It was hallowed as a triumph of the righteous over the wicked. But the battle lines were never clearly drawn. The real war, the war between good and evil, is fought within ourselves.

"Contradiction is uncomfortable. And it can be easier to pick one story to tell ourselves so that we don’t have to deal with that discomfort. So that we don’t have to do the work of finding the middle ground. But when we only choose one story and ignore the ones that contradict it, we end up lying to ourselves. And we may find we get to a point where we don’t recognize the truth at all anymore."

"Contradictions are not easy to live with. They are reminders of where we have fallen short. Where we have failed. But I think they can also be a roadmap. They point out where we can do better and they can show us the things we truly value. And maybe that will make it a little easier to deal with."

Source: Complexities, Contradictions, and the Culper Spy Ring - The Ink Bottle of Shanelle Sorensen

( https://shanellesorensen.com/complexities-contradictions-and-the-culper-spy-ring/ )

The Wildland Firefighter’s 23rd Psalm

The Lord is my Incident Commander;

I will have all the resources I really need.

He makes me adhere to work-rest guidelines;

He gives me quiet moments of refreshing as I overlook His creation.

He overwhelms me with His peace and presence.

He leads me in paths of integrity and righteousness

So that other will realize that He is good.

Even though the fire blows up, though trees fall all around me, though others may fall and my escape route seems cut off, I will not be afraid, for you are with me.

Your voice guides me to a safety zone. I find shelter with you.

You break out MREs even as the fire roars around us.

You affirm your confidence in me;

You patch up my cuts and scrapes;

You keep me from going the wrong direction when my compass seems broken.

I feel peace and contentment like I’ve never felt before.

I know that I will have your presence with me;

I will never be out of radio contact wherever I go, on and off the line.

And I will remain on your team, be part of your team, forever.

Source: Rick Barton. Answering the Call. (NIV) Fellowship of Christian Firefighters International (FCFI)

Edits June 30, 2013 8 AM. Added hyperlink to a source website, additions to SAIT-SAIR references to Escape Routes, added quote, added Wildland Firefighter's 23rd Psalm.

Source: https://www.tis.edu.mo/news/remembrance-day/


6-22-13 1:29pm Chris MacKenzie IMG_0869 

Source: Yavapai County Records/SAIT Report/Documents.

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