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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.