• Joy A. Collura and (emphasis added here on these 5

Part 1 of 5 - Underneath every simple, obvious story about human error,’ there is a deeper, more co

Part 1 of 5 - Underneath every simple, obvious story about ‘human error,’ there is a deeper, more complex story - a story about the system in which people work. Will these formerly unrevealed public records change the account of what occurred on June 30, 2013?

"But if serving the LORD seems undesirable to you, then choose for yourselves this day whom you will serve, whether the gods your ancestors served beyond the Euphrates, or the gods of the Amorites, in whose land you are living. But as for me and my household, we will serve the LORD." Joshua 24:1 (NIV)

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 ( )

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. Our sincerest apologies for the delays. These posts were due out in August 2019 yet we had website research a matter, and we are now finally able to rebuild the pages and make them "live." This extensive post may offend some due to the time of the year, however, we must stay the course to release information because more is yet to come out in future posts. To avoid such offense to some, please avoid further reading the posts until you find a proper reflective time for yourself. I did ask many people who were affected by this tragic Yarnell Hill Fire event and they said it was okay to post it this weekend. I know some people would not want any of this out at any time, yet I also know too many for "mental health" reasons need this out ASAP. Again - please avoid reading any further if you are unable to handle "sensitive material." Thank you.

To underpin and underscore pertinent issues in this post, we begin by addressing several important leadership and human factors issues discussed in the Serious Accident Investigation Team ( SAIT ) - Serious Accident Investigation Report ( SAIR ) and other publications and venues, many that are Yarnell Hill Fire (YH Fire) specific, prior to delving into the July 2019 Applied Human Factors and Ergonomics ( AHFE ) Conference images and issues presented in Washington, DC.

Figure 1. June 30, 2013, 1629 (4:29 PM) Yarnell Hill Fire image of very aggressive fire behavior taken from near the Ranch House restaurant in Yarnell along Hwy. 89 with the Weaver Mountains in the background. Source: Brian Lauber, WTKTT, Google Earth

This photo above is a key component for examining and discussing the YH Fire and Granite Mountain Hot Shots (GMHS) tragedy. As posted elsewhere on this website, the original photo (without Google Earth overlay) was given to the so-called Lead "Investigator" of the Serious Accident Investigation Team (SAIT) early on, however, it was never used or even referred to in the SAIT-SAIR. Instead, the SAIT-SAIR provided an "idealized image" on page 77 as "Figure 18" that gives a completely false representation of what actually occurred. The SAIT-SAIR falsely claimed that there was fire above and below the GMHS basically trapping them. Clearly, there is no fire visible above in this Figure 1 photo.

The title of this post, and the subtitle of our paper, are derived from a quote by Human Factors author and researcher Sidney Dekker in "Field Guide to Understanding 'Human Error" 3rd Edition, p. 5 (2006). “Underneath every simple, obvious story about ‘human error,’ there is a deeper, more complex story about the organization.” Dekker, in a subsequent research paper, talks about what this deeper more complex story and systems in what he refers to as "complexity and systems thinking" in his Lund University paper titled as a noteworthy question requiring a noteworthy answer: "In the system view of human factors, who is accountable for failure and success?" Dekker's research paper, along with over 30 other papers, is published within the Human Factors and Ergonomics Society Europe Chapter Annual Meeting in Linköping, Sweden, October 2009 book titled: "Human Factors - A system view of human, technology and organisation" is available in the links immediately below.

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Dekker, Sidney. Human Factors: A system view of human, technology and organisation, Maastricht, the Netherlands: Shaker (2010). ( )

However, he does make this one debatable statement: "Formal, government-sponsored accident investigations enjoy this aura of objectivity and truth ..." (emphasis added) I disagree with this statement regarding government-sponsored investigations being objective and truthful. But then he may be talking about his own Government and certainly not our Government, which has a totally different impression of objectivity and truth, discussed in some detail in this post and elsewhere in other research papers and books, and on this website.

Dekker states: "The consequence for the ethics of failure is that there can be only one true story of what happened. In Newtonian epistemology, the “true” story is the one in which there is no more gap between external events and their internal representation. (i.e. those who, without any bias that distorts their perception of the world, will consider all the facts) are better poised to achieve such a true story." (emphasis added) In the system view of human factors, we are attempting to discover who is accountable for failure and success.

One of the primary goals of this website and these posts will always be to continually seek clues to the human behavior that cost these 19 young men their lives on June 30, 2013. These are things we need to know even though we may not fully understand, and therefore "The search for truth implies a duty. One must not conceal any part of what one has recognized to be true." Albert Einstein

Consider now the Part 1 of 5 posts, each consisting of a PDF (converted to JPEG) of our original "Formerly Unrevealed Public Records Should Change the Account of What Occurred on June 30, 2013. Underneath every simple, obvious story about 'human error.' there is a deeper, more complex story ... a story about the system in which people work" Power Point presentation. The PDF JPEG post differs from the originally published paper included in this link, in that it contains much more detail on each of the topic areas, especially the Sesame Street and Shrine Fuel / Fire Break Corridor area firing operation.

The presentation was given at the Applied Human Factors and Ergonomics ( AHFE ) 2019 International Conference jointly within the sub-conference on the 3rd International Human Error, Reliability, Resilience, and Performance, July 24-28, 2019, Washington D.C., USA . ( )

Figure 2. PDF JPEG image of Title slide "Formerly Unrevealed Public Records Should Change the Account of What Occurred on June 30, 2013. Underneath every simple, obvious story about 'human error.' there is a deeper, more complex story ... a story about the system in which people work." Source: Schoeffler, Honda, Collura, Dekker

The 2019 AHFE Conference paper with the same title is published within the Advances in Human Error, Reliability, Resilience, and Performance group. Included in these PDF conversions are more details about whether there truly was a Sesame Street and Shrine Corridor Firing Operation area. ( ).

"How liars create the 'illusion of truth.' Repetition makes a fact seem more true, regardless of whether it is or not. Understanding this effect can help you avoid falling for propaganda, says psychologist Tom Stafford. ... 'Repeat a lie often enough and it becomes the truth, is a law of propaganda often attributed to the Nazi Joseph Goebbels. If repetition was the only thing that influenced what we believed we'd be in trouble, but it isn't. We can all bring to bear more extensive powers of reasoning, but we need to recognize they are a limited resource. Our minds are prey to the illusion of truth effect because our instinct is to use short-cuts in judging how plausible something is. Often this works. Sometimes it is misleading. Once we know about the effect we can guard against it. Part of this is double-checking why we believe what we do – if something sounds plausible is it because it really is true, or have we just been told that repeatedly? This is why scholars are so mad about providing references - so we can track the origin on any claim, rather than having to take it on faith. But part of guarding against the illusion is the obligation it puts on us to stop repeating falsehoods. We live in a world where the facts matter, and should matter. If you repeat things without bothering to check if they are true, you are helping to make a world where lies and truth are easier to confuse. So, please, think before you repeat." (emphasis added) BBC Future. Psychology. Tom Stafford. 26 October 2016 ( )

Wildland firefighting is often likened to a type of warfare and its firefighters as warriors, so a brief discussion of a very unique warrior culture follows.

"Out of every one hundred men, ten shouldn't even be there, eighty are just targets, nine are the real fighters, and we are lucky to have them for they make the battle. Ah, but the one, one is a warrior, and he will bring the others back." - Heraclitus (534-474 B.C.) (emphasis added)

The Spartan army was comprised of citizens trained in the disciplines and honor of a warrior society and stood at the heart of the Spartan state; young men subject to increasingly intense military drill from early manhood to become one of the most feared warrior nations in the Greek world. At the height of their power being labeled as lacking vigor was cause for shame and ridicule. (History Channel - Sept. 1, 2018) ( (Gates of Fire - S. Pressfield) (

This rigorous training was indeed necessary for times like these: “There was an exercise we of the battle train practiced when we served as punching bags for the Spartan heavy infantry. It was called the Oak because we took our positions along a line of oaks at the edge of the plain of Otona, where the Spartiates and the Gentleman-Rankers ran their field exercises in fall and winter. We would line up ten deep with body-length wicker shields braced upon the earth and they would hit us, the shock troops, coming across the flat in line of battle, eight deep, at a walk, then a pace, then a trot and finally a dead run. The shock of their interleaved shields was meant to knock the breath out of you, and it did. It was like being hit by a mountain. Your knees, no matter how braced you held them, buckled like saplings before an earthslide; in an instant all courage fled our hearts; we were rooted up like dried stalks before the ploughman’s blade.” (emphasis added) (Gates of Fire - Steven Pressfield)

"Although extraordinary valor was displayed by the entire corps of Spartans and Thespians, yet bravest of all was declared the Spartan Dienekes. It is said that on the eve of battle, a native of the district appeared in camp spreading alarm by his report of the numbers of the Persian archers. So vast were these myriads, the scout declared, that when they fired their volleys, the mass of arrows blocked out the sun. Dienekes, however, quite unfazed by the prospect of dueling such multitudes, remarked only, 'Let the Persians hide the sun; we’ll fight them in the shade.'” (emphasis added) (Pressfield)

Wildland Firefighters are certainly NOT Spartan warriors. However, it is always good to compare and contrast the leadership and work ethic traits of all types of military warriors to WFs and FFs that engage in the quasi-military realm of wildland firefighting.

Consider now Part 1 of 5 posts, each consisting of a PDF (converted to JPEG) of our original "Formerly Unrevealed Public Records Should Change the Account of What Occurred on June 30, 2013. Underneath every simple, obvious story about 'human error.' there is a deeper, more complex story ... a story about the system in which people work" Power Point presentation. The PDF JPEG post differs from the originally published paper included in this link, in that it contains much more detail on each of the topic areas, especially the Sesame Street and Shrine Fuel / Fire Break Corridor area firing operation. The presentation was given at the Applied Human Factors and Ergonomics ( AHFE ) 2019 International Conference jointly within the sub-conference on the 3rd International Human Error, Reliability, Resilience, and Performance, July 24-28, 2019, Washington D.C., USA .

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Figure 3. PDF JPEG image of Introduction and major elements to be discussed slide. Source: Schoeffler, Honda, Collura

This is the basic outline of our Washington, DC AHFE PowerPoint presentation and this Part 1 to 5 Formerly Unrevealed Public Records post will follow it as closely as possible with additions and variations.

Figure 4. PDF JPEG image of Fairly standard Disclaimer promoting Lessons Learned and Entrapment Avoidance for WF and FF safety, noting the "authors' views," the use of "anonymous-by-request' contributors, and warning that some content may be considered by some to be graphic, disturbing, and / or offensive. Source: Schoeffler, Honda, Collura

Figure 5. PDF JPEG image of Arizona map (left) and Google Earth detail image (right) depicting Sesame Street and Shrine Corridor, upslope orientation, twin parallel chutes and chimneys in alignment with the GMHS Deployment Zone. Source: Schoeffler, Honda, Collura

You are encouraged to focus on this Google Earth image in Figure 5 a lot because it will become very useful (and necessary) as you read down through the post viewing the numerous photographs and videos of separate and distinct smoke columns (plumes) from the likely firing operation that occurred in the Sesame Street and Shrine Fuel / Fire Break Corridor area.

From a purely Fire Weather perspective, it is a permissible inference to state that, most experienced WFs, FFs, and Supervisors would find it interesting and informative that the motto for Yarnell is "Where the Desert Breeze Meets the Mountain Air." I say this because the way the Yarnell Hill Fire burned on June 30, 2013, was indicative of that type of desiccating and driving, hot desert air influence on the fire behavior on many wildland fires in Arizona, but especially on this tragic fire. This unique local fire weather factor (Watch Out # 4) is addressed in the July 2013 USA Today article below. And from a purely human factors perspective, it sure seems that the local GMHS were actually unfamiliar with these local factors in their own response area, especially considering that they had worked on the Doce Fire a week before exhibiting aggressive fire behavior.

The following is from a July 2, 2013, USA Today article titled: "Arizona officials seek answers after 19 firefighters die." "During the monsoon, the searing desert temperatures force columns of hot air high into the atmosphere, Leuthold and National Weather Service meteorologists said." On Sunday, meteorologists measured the thermals as high as 22,000 feet — halfway through the atmosphere. The readings were among the highest they’d ever seen. Brian Klimowski, the National Weather Service’s meteorologist in chief in the Flagstaff division, said local topography could channel winds into even stronger gusts, making fire behavior more unpredictable. ... The fire itself was a beast.“Guys on the ground told me the fire behavior was as extreme as anything they’d ever seen,” Dugger Hughes of the Southwest Coordination Center, an inter-agency organization in New Mexico said. ... What forensic pathologists will find will be important in learning how quickly the fire passed over the Prescott firefighters. ... “Charlie Gripp, a Federal Emergency Management Agency consultant and a former fire-operations safety officer for the U.S. Forest Service" said "they’ll go over all the qualifications, make sure there were no obvious over-sights by leadership,” he said. “They’ll look at the training they had: How good was it? Was it done timely and right? ... " (emphasis added) Source: "Arizona officials seek answers after 19 firefighters die" by Craig Harris, Sean Holstege and Bob Ortega, The Arizona Republic. Published 3:39 p.m. ET July 2, 2013 | Updated 4:08 p.m. ET July 2, 2013.

The fire weather was at its potential peak intensity for aggressive to extreme fire behavior based on the NWS observations, readings, and comments. And the comments made by Hughes (SWCC) and Gripp (FEMA) are instructive. Did the SAIT actually look into these detail areas and if so, how much consideration did they give them in their investigation and SAIR? I think it's fair to say - very little, if at all, because it's certainly not reflected in their "factual" SAIT-SAIR with the conclusion quoted below.

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The idealized "Sunday's Shifting Winds" images from the link below reveal the intensity and time-frames of the June 30, 2013, YH Fire winds that occurred as a result of the approaching thunderstorm outflow winds. These winds fueled the fire with oxygen and funneled the fire through the deadly terrain mechanisms detailed below. The middle idealized image is most germane since the GMHS were burned over in their Deployment Site around 4:48 PM (1648). ( ) Monday afternoon / evening to 5:29 p.m.: Reporter McKinnon reports further on how the weather played into tragedy, “When the weather changed,” he writes, “it turned a bad situation deadly.” "Wildfire experts: More than 1 factor spawned Yarnell tragedy Fuels, thunderstorm likely contributed to deadly fire condition" Shaun McKinnon The Republic | - Tue Jul 2, 2013 12:38 PM

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I firmly believe "Forensic Weather" experts are the future for Wildland Fire Industry so we should "fact check" what the media places out to us.

Figure 5a. Idealized image of weather, respective wind shifts, wind speeds, and wind directions from 3:00 PM at 24 mph (left), 5:00 PM at 42 mph (middle) and 7:00 PM at 22 mph (right) Stanton, AZ remote weather station Source: Arizona Republic

Figure 6. PDF JPEG image of the Wildland Firefighting Rules (e,g, Ten Standard Fire Orders) and Guidelines (Eighteen Watch Out Situations). Source: Schoeffler, Honda, Collura

Based on dialogues with numerous WFs / FFs / USFS WFs and my research - they consistently stated immediately after the YH Fire, there began an intensive movement by many of the SAIT members, Subject Matter Experts (SMEs), and select U.S. Forest Service personnel to discredit these tried-and-trued Rules of Engagement. They visited numerous USFS Ranger Districts during their Critical and/or Refresher Training sessions, Wildland Fire Training Academies, Wildland Fire Apprenticeship Academies, and many other forums to discredit the "10 and 18" as being ineffective "because 19 men died." These USFS WFs were directed to consider the Ten Standard Fire Orders as "Guidelines" instead of Orders (the 18 Watch Out Situations are guidelines) and to focus only on the "official" SAIT-SAIR for information because the SAIT officially found "NO INDICATION OF NEGLIGENCE, RECKLESS ACTIONS, OR VIOLATIONS OF POLICY OR PROTOCOL.” (emphasis added) SAIR (2013) p. 4.

Bear in mind that the wise man David Hume once said: "In our reasonings concerning matter of fact, there are all imaginable degrees of assurance, from the highest certainty to the lowest species of moral evidence. A wise man, therefore, proportions his belief to the evidence." David Hume, (Enquiries Section X: Of Miracles; Part I. 87). I think he means that the strength of our beliefs should depend upon the strength of the evidence available or presented. Therefore, we should base our opinions on what and where the evidence (and the powers of our reasoning), guides us. And since most evidence leaves room for at least some doubt, we should always remain somewhat skeptical of what we believe.

Instructors at National USFS Wildland Fire Apprenticeship Academies, various quasi-private / municipal Wildfire Training Academies, and local USFS Ranger Districts were required to cite and utilize, and therefore, follow only the SAIT-SAIR "conclusions" and what is presented in the associated YH Fire SAIT PowerPoint and "briefing video." And USFS Apprenticeship Instructors were required to provide lesson plans for "Regional Office and Washington Office approval" if they were to discuss anything at all about the Yarnell Hill Fire.

These official "nationally recognized" and alleged self-proclaimed "progressive thinkers" used the fallacious argument based on the SAIT-SAIR no fault conclusion to boldly claim that the WF Rules don't work as evidenced by the nineteen dead GMHS. This deceptively insidious ploy continues to this day and is covered further in Figure 30 in Part 2 of 5 in this post and elsewhere on this blog.

Quotes from the following article (below) are pretty informative and insightful. Stephan Lewandowsky et al (2012)

Misinformation and Its Correction: Continued Influence and Successful Debiasing. Psychological Science in the Public Interest, 13. ( )

I will now take those quotes and "fill in the blanks" with [bracketed] relevant wildland firefighting words and phrases to make it germane to the wildland firefighting realm. The author also wrote a subsequent (2017) paper titled: "Beyond Misinformation: Understanding and coping with the post-truth era" on the same misinformation subject matter.

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Consider first the original quote: "It is a truism that a functioning democracy relies on an educated and well-informed populace. (citation omitted) The processes by which people form their opinions and beliefs are therefore of obvious public interest, particularly if major streams of beliefs persist that are in opposition to established facts. If a majority believes in something that is factually incorrect, the misinformation may form the basis for political and societal decisions that run counter to a society’s best interest; if individuals are misinformed, they may likewise make decisions for themselves and their families that are not in their best interest and can have serious consequences." Lewandowsky et al (2012) (emphasis added)

Okay, so now let's consider the same logic when we put the above quote into a WFs perspective by "filling in the blanks" in bolded red. It is a truism that a functioning [wildland firefighting culture] relies on an educated and well-informed [pool of wildland firefighting resources]. The processes by which [these WFs and FFs] form their opinions and beliefs are therefore of obvious [human factors] interest, particularly if major streams of beliefs persist that are in opposition to established facts. If a majority believes in something that is factually incorrect, the misinformation may form the basis for [wildland firefighting tactical and strategic] decisions that run counter to a [wildland firefighting resource's] best interest; if individuals are misinformed, they may likewise make decisions for themselves and [those they are responsible for] that are not in their best interest and can have serious consequences.

Consider now the second quote on smoking: "... the persistence with which vested interests can pursue misinformation is notable: After decades of denying the link between smoking and lung cancer, the tobacco industry’s hired experts have opened a new line of testimony by arguing in court that even after the U.S. Surgeon General’s conclusion that tobacco was a major cause of death and injury in 1964, there was still “room for responsible disagreement.” (citation omitted) Arguably, this position is intended to replace one set of well orchestrated misinformation—that tobacco does not kill—with another convenient myth—that the tobacco industry did not know it. Spreading doubts by referring to the uncertainty of scientific conclusions—whether about smoking, climate change, or GM foods—is a very popular strategy for misinforming the populace." Lewandowsky et al (2012) (emphasis added)

Likewise, let's put the above into a WFs perspective by "filling in the blanks" with bolded red excerpts. "The persistence with which vested interests can pursue misinformation is notable: After decades of denying the link between [safe wildland firefighting by utilizing basic WF Rules and avoiding wildfire burnovers and fatalities], the [Wildland Fire Lessons Learned Center and upper-level wildland fire management] experts have opened a new line of testimony by arguing [in Two More Chain posts and Podcasts and the SAIT-SAIR Briefing Videos] that even after the [Wildland Fire Lessons Learned Center Honoring the Fallen video] conclusion that [following the 10 & 18 and WF Rules] was a major cause of death and injury in [all cases], there was still room for [luck decision conversations]. Arguably, this position is intended to replace one set of well-orchestrated misinformation—that [luck decision conversations] do not kill — with another convenient myth — that the [wildland firefighting culture that followed the Basic WF Rules, i.e. 10 & 18] did not know it. Spreading doubts by referring to the uncertainty of scientific conclusions —whether about [knowing and following the 10 & 18], climate change, [mega fires], or [political correctness]—is a very popular strategy for misinforming the populace [and the wildland firefighting resources and culture]."

"Old School" WFs and Hybrid FFs - and those that subscribe to the "Old School" concept - know that these Basic WF Rules work every time they are properly utilized and applied, hotly oppose the "Progressive Thinkers" and their use of the "Honoring the Fallen" as an emotional pretense. Worst of all, we dishonor the dead by not telling the truth about what contributed to and / or caused their deaths. I allege that it is because what they really want is to use smoke and mirrors and subtle deception to convince you that the GMHS did no wrong and that it could happen to anyone because the 10 & 18 have never worked. There are always going to be other WFs/ FFs/ Smokejumpers that believe that the Fire Orders are guidelines, and I have a respect for them but not their beliefs.

"OLD SCHOOL" MATTERS as much as it is to bridge it to the new current ways!

So then, even though I have had some private sector wildland fire training and experience and the Basic S-130 / 190 training, other than my time on the Weaver Mountains on June 28-30, 2013, I have never actually fought a wildfire. However, I struggled for years on InvestigativeMEDIA with Bob Powers and RTS when they posted that the "10 and 18" and LCES work all the time. I have said for years that one cannot always follow the Ten Commandments, so how can one always follow the "10 and 18" and LCES. Since then, in my research, I have been unable to locate even one wildland fire mishap and / or investigation report where they followed the "10 and 18" and LCES and were entrapped, deployed fire shelters, injured, or killed.

In 2002, Jerry Williams, the former Director of Fire and Aviation Management, USDA Forest Service, Washington Office, Washington, DC, wrote an article for Fire Management Today (Issue 62, pp. 31-35) that specifically addresses the value of the Fire Orders. 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. It is most unfortunate that so many in the wildland firefighting culture have strayed far and wide from this sage counsel.

In other words, this germane wildland fire information and these valuable lessons learned that Mr. Williams offered in 2002, were clearly available to ALL WFs and FFs engaged in wildland firefighting in 2013, including the GMHS. Apparently, all others on the YH Fire that day followed Mr. William's sage advice. And literally tens of thousands of WFs and FFs engaged in wildland firefighting effectively and safely utilize them every single fire season. This is factual and NOT hindsight bias!


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. (emphasis added) (Williams 2002) Unfortunately, many of today's WFs and FFs engaging in wildland firefighting do not subscribe to this professional advice. And worst of all, the Investigation Teams or Learning Reviews refuse to utilize these as a template or standard any longer.

“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. (emphasis added) (Williams 2002) For "complete" lessons learned, the proactive "entrapment avoidance" training should be mandatory instead of the alleged "factual" SAIT-SAIRs of all the historical wildland firefighting mishaps - fatal and otherwise - that disingenuously and falsely conclude no fault, no blame, no violations of policy, protocol, or procedure.

“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." (emphasis added) (Williams 2002) The system is already in place to speak up, however, the actual results are mixed, inconsistent, and discouraging, thus promoting non-compliance.

“Following an accident, a “stand -down” 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. (emphasis added) (Williams 2002) Unfortunately, this "culture" has long been abandoned by management.

“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.” (emphasis added) (Williams 2002) This is basically the "Old School" way of wildland firefighting. And unfortunately, we fail to learn "complete" lessons because we are told that there was no blame, no fault, and no indications of any of these due to human factors.

And once again, the challenge is still out there to all you WFs and Smokejumpers and FFs engaged in wildland firefighting to provide even one wildland fire where the Fire Orders, LCES, were followed, and the 18 Watch Outs were utilized and mitigated, and a WF or FF was entrapped, deployed a fire shelter, or was killed by the wildfire.

This “FAILURES IN WILDLAND OPERATIONAL LEADERSHIP – 2006 through 2007” paper discusses, from an experienced USFS WF Supervisor's perspective, four wildland fires (including Little Venus Fire) from 2006- 2007 where “failures in judgment and faulty application of principles of fire suppression operations have been documented in review findings.” (emphasis added) He discusses the "incomplete" application of LCES, human factors, situational awareness (MOSTLY LACK OF), and leadership (or lack of) that result in unplanned, unanticipated burnovers and fire shelter deployments.

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The following research paper is a fairly excellent one that was written by a USFS Smokejumper that turned academic. However, I disagree with at least this assertion: "It has been understood for some time that the number of firefighting rules and regulations imposed upon the line firefighter has become unwieldy." He then posits his, what I feel, quite complicated TEFF proposal as a viable replacement for the basic WF Rules.. Patrick Withen (2005) TEFF: THE TEN ESSENTIAL FACTORS IN FIREFIGHTING. Butler, B.W and Alexander, M.E. Eds. 2005. Eighth International Wildland Firefighter Safety Summit- Human Factors - 10 Years Later; April 26-28, 2005 Missoula, MT. The International Association of Wildland Fire, Hot Springs, SD. Patrick Withen is/was an Associate Professor of Sociology and Organizational Studies and Chair of the Dept. of Social Sciences at the University of Virginia at Wise, and was a Smokejumper for the U.S. Forest Service, out of McCall, ID. (

DocumentFileKey=06446a2f-7dff-4fbe-8677-4032063067fd&forceDialog=0) Unable to hyperlink this one, so you'll need to cut and paste the link to locate it.

Wildland firefighting functions as a quasi military operation with both a vertical and horizontal chain of command, somewhat fixed formal and informal authorities and responsibilities, following orders, etc. There has been a favorable movement afoot, with some WF Supervisors, for some time now, delving into what is referred to as "shared leadership" covered in some of the papers listed below. Similarly, the Israeli Defense Force (IDF) "Tenth Man Rule" is well worth looking into. It advocates a "Devil's Advocate" role to counter the insidious known hazardous attitude of Group Think that is endemic to small, cohesive groups like military special operations and wildland firefighters.

( ) ( ) Unfortunately, yet unsurprisingly, according to experienced WFs, there are NO research papers SPECIFICALLY that I know of on the subject of following or (dis)obeying orders dealing specifically with Wildland Firefighting. All are about and from a military perspective. Ask any experienced WF or FF engaged in wildland firefighting, and they will have at least one experience of "being shipped to Division Siberia" (somewhere the fire edge is out!) and/or being sent home for refusing an unsafe, illegal, immoral, or unethical order while offering more tenable alternative options.

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Osiel, M.J. (1998) Obeying Orders: Atrocity, Military Discipline, and the Law of War. California Law Review Volume 86, Issue 5 Article 1.

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Osiel wrote an excellent paper considering its age because he covers a lot of the history and background on the subject.

To Obey, or Not to Obey?

"So, to obey, or not to obey? It depends on the order. Military members disobey orders at their own risk. They also obey orders at their own risk. An order to commit a crime is unlawful. An order to perform a military duty, no matter how dangerous, is lawful as long as it doesn't involve the commission of a crime.

"You can’t just decide not to disobey an order because you don’t want to — you have to be confident that you are doing so in accordance with the ethics of your profession. And you had better be prepared to face the consequences if you are wrong." (emphasis added) What to Know About Obeying an Unlawful Military Order

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"Military leaders must have the courage to speak truth to power and insist on access to the decision maker."

"'In war the first principle is to disobey orders. Any fool can obey an order. He ought to have gone on, had he the slightest Nelsonic temperament in him.' (emphasis added) So wrote First Sea Lord Jacky Fisher in angry critique of Capt. H.M. Pelly, a cruiser captain under Adm. Beatty at the Battle of Dogger Bank in 1915." When decision makers placed in these circumstances, they must accept the risk of audacity. This is an interesting historical narrative dealing with communications and human factors worth researching.

The wildland firefighting realm firmly endorses the "How To Properly Refuse Risk" with such sources as this: Refusing Risk (NWCG IRPG and 6-Minutes For Safety - July 2019) (

Please recall that WFs and FFs must follow orders UNLESS they are: (1) Illegal; (2) Unsafe; (3) Unethical; or (4) Immoral. Stupid doesn't count. Often, however, WFs and FFs must follow "stupid orders" while staying within the safety realm of the WF Rules in order to prove the point that the orders are in fact stupid, a waste of time, effort, money, opportunity, and much more. Please take the time to read The Morality of Obeying Stupid Orders by John Reed. ( )

Figure 7. PDF JPEG image of the classic Swiss Cheese Model by James Reason (Manchester, England) and directed generally toward the YH Fire and specifically to the GMHS. Source: Reason, Schoeffler, Honda, Collura

'The Swiss Cheese Model is frequently referred to and widely accepted in human factors circles. However, because there is no clear evidence that the Swiss Cheese metaphor is understood in the same way by all concerned, a brief refresher follows.

'The vertical Swiss cheese blocks indicate barriers within an organization and the holes within each block of your organization indicate weaknesses, so that when the holes line up, it means one weakness carried over into another weakness and so on, thus it creates a single hole throughout the organization with the potential to cause an accident.

'The idea of successive defense layers being broken down helps in understanding that things are linked within the system, and intervention at any stage - particularly early on - could stop a disaster from unfolding. Reason designed the model after years of in-depth research into the nature of accidents, which led him to the following insights:

'(1) Accidents are often caused by the confluence of multiple factors; (2) Factors can range from unsafe individual acts to organizational errors; (3) Many contributing factors to an accident are latent errors – they’re lying dormant waiting to be triggered by any number of active errors; and (4) Humans are prone to operational errors which require properly designed systems to mitigate the errors humans inevitably commit.'

Reason then determined that there were both active and latent failures, (i.e. the holes within the cheese). Other research indicates that nearly all adverse events involve a combination of these two sets of factors.

'Active Failures - Active failures or active errors are the unsafe acts committed by people. An example of an active failure would be an employee who chooses not to follow safety procedures like failing to wear sleeves rolled down on their fire shirts (PPE) while on the firelines. And worse yet, their supervisors setting a poor example by following suit with their sleeves rolled up and /or failing to comply with their supervisory responsibilities and failing to correct the infractions in the first place.

Latent Condition - Loosely equivalent to causal factor or contributing factor. Latent conditions or latent errors include contributory factors that lie dormant for days, weeks, months, or even years until they contribute to the accident. They are the failures built into procedures, systems, by the labor force or management. Latent conditions 'are failures waiting to be triggered by an active error'.

As stated above, an example of a latent condition would be supervisors failing to correct errant behavior or faults of those th