- Joy A. Collura and emphasis added here on these
Part 2 of 5 - Underneath every simple, obvious story about human error, there is a deeper, more
Part 2 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?
"For we wrestle not against flesh and blood, but against principalities, against powers, against the rulers of the darkness of this world, against spiritual wickedness in high places." (Ephesians 6:12 - KJV)
Views expressed to "the public at large” and "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. Our sincerest apologies for the delays. These posts were due out in August 2019 yet we had WIX.com 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.
Before we begin, this is a First Amendment issue addressed "to the public at large" because we have the right, and the obligation, to thoroughly examine and reveal the details of Yarnell Hill (YH) Fire debacle and the Granite Mountain Hot Shot (GMHS) tragedy - something the Serious Accident Investigation Team clearly failed to do. I feel the need to express that these YH Fire and GMHS issues are sensitive and uncomfortable matters to bring forward. WFs, FFs, and the general public are starving for information on this issue. So, I am sharing what I know from personal experience and people's feedback about the InvestigativeMEDIA (IM) blog - that it aroused contention, even aggression, and anxiety. We need to talk about these matters sooner, than later. To meet and get to know some of the GMHS family, friends, and loved ones - and being in that situation - is challenging enough; to engage in theses dialogues and communications could either compound the problem, which sometimes makes it worse, or we can take the road to minimize our "fall-outs" or disagreements in a respectful manner. One of the nuggets I want to communicate is - however long it takes me, there will be one concise memorable message. I have learned that I may have gathered (received) too much information and this, at times seems to be all too complicated and layered. So, to mitigate that, I have been "going to school" to educate myself about the wildland fire world in order to show you - the world - how serious the YH Fire and GMHS issue is. In closing, this is extremely emotional, time consuming, and to do what I am doing has the potential for confrontational situations (which I try to avoid). I know what I'm doing is the right thing to do. Those young men should never have died, those homes should never have been destroyed, and our lives should have never been affected by this tragedy fire. When reading this blog, you may not comprehend or remember everything you read, but you will remember how it made you feel while reading it. I wish I had the topic to make one "feel great" even though it is a difficult situation, so I'm doing my best to relate to those affected in a very open and humane way. We address the decisions and actions and outcomes of these Wildland Firefighters (WFs) and Firefighters (FFs) and avoid making personal "ad hominem" attacks. I never thought my life would be so detailed or fixated on anything like this. We are focused here on "complete lessons learned" toward lessening the inevitable wildland fire tragedies that are unfortunately likely to occur. Some GMHS family members have expressed that I can walk way from this, yet they cannot walk away because of how close they are. I think about those young men and this fire every day (as well as so many others) and this is the path God has led us to follow.
Consider now the Ninth Circuit ruling on a First Amendment issue concerning the Crystal Cox vs. Obsidian Finance Group case on the rights of free speech in a "matter of public concern," a key component. The justices' holding vindicated Ms. Cox and allowed her the same free speech protections as journalists, (i.e. when truth survives free speech).
Obsidian Finance Group vs. Crystal Cox ( http://cdn.ca9.uscourts.gov/datastore/opinions/2014/01/17/12-35238.pdf )
Hull, Tim (17 January 2014). "Blogger's Speech Rights Championed in the 9th". Courthouse News Service. Retrieved 2 February 2014.
"I think it sets an important precedent that bloggers, for First Amendment purposes, have the same rights as others do, as for example the institutional media does," Volokh said in a phone interview. "There have been plenty of past cases around the circuits that point in that direction, but this is the first time that the 9th Circuit has specifically ruled on this, and this is one of the cases that has focused on bloggers. Most cases have dealt with other nonprofessional media, but this one is particularly the first clear blogging case that I know from the circuit courts." (emphasis added)
( https://www.courthousenews.com/Bloggers-Speech-Rights-Championed-in-the-9th-/ )
9th Circuit Issues a Blogger-Friendly First Amendment Opinion–Obsidian Finance v. Cox ( https://blog.ericgoldman.org/archives/2014/01/9th-circuit-issues-a-blogger-friendly-first-amendment-opinion-obsidian-finance-v-cox.htm )
When Truth Survives Free Speech ( https://www.nytimes.com/2011/12/12/business/media/when-truth-survives-free-speech.html?auth=login-email )
Blogger gets same speech protections as traditional press: U.S. court
( https://www.reuters.com/article/us-usa-blogger-ruling/blogger-gets-same-speech-protections-as-traditional-press-u-s-court-idUSBREA0G1HI20140117 )
U.S. Court: Bloggers Are Journalists - Even when they're libeling you
Obsidian Finance Group vs Cox Law School Review (https://willamette.edu/law/resources/journals/wlo/9thcir/2014/01/obsidian-finance-group-v.-cox.html)
"In defamation suits, the matter at issue must be of public concern and a plaintiff must show that the defendant acted negligently in publishing an assertion of fact, regardless of whether the writer is a member of the institutional media." (emphasis added)
( http://cdn.ca9.uscourts.gov/datastore/opinions/2014/01/17/12-35238.pdf )
"The Ninth Circuit found this case fell in the grey area between the defamation standards for public figures, which require a showing of actual malice, and private defamation suits under a negligence standard pursuant to Gertz v. Robert Welch, Inc. Declining to base First Amendment protections on whether a speaker is a journalist, the panel held that Gertz is not limited to institutional media defendants, and case law supports not providing institutional media with greater protection than other speakers. The panel also held that the blog post was of public concern ... The panel also affirmed the district court’s summary judgment on the other blog posts, finding them to be pure opinions and lacking an assertion of objective fact." (emphasis added)
The Ninth Circuit Holds—Correctly—That a Blogger Has the Same Defamation Protection as a Journalist ( https://verdict.justia.com/2014/02/03/ninth-circuit-holds-correctly-blogger-defamation-protection-journalist )
Protecting The Free Speech of Censors: The Crystal Cox Saga
( https://www.popehat.com/2014/01/19/protecting-the-free-speech-of-censors-the-crystal-cox-saga/ )
Obsidian Finance Group vs. Cox - Wikipedia
( https://en.wikipedia.org/wiki/Obsidian_Finance_Group,_LLC_v._Cox )
To underpin and underscore pertinent issues in this post, we begin by addressing several important issues discussed in other wildland fire fatality Learning Reviews and 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.
This Part 2 of 5 section contains information, data, images and photographs, videos, and links on the following: Ninth Circuit First Amendment caselaw; the Coordinated Response Protocol (CRP) and Learning Reviews; former Yarnell Hill Fire Chief Peter Anderson (RiP); Sesame Street and Shrine Fire / Fuel Break Corridor Fuel Treatment activities and projects; the Wildland Fire Lessons Learned Center (LLC) and their alleged "Honor the Fallen" series; "securing the scene" of the YH Fire GMHS deployment / fatality site; the legal Touhy Principle and Federal Housekeeping statute that the Federal Government utilizes to control what their employees are "allowed" to share in records, testimony; the disparate treatment of USFS Aerial Firefighting Utilization and Effectiveness (AFUE) Study; Freedom of Information (FOIA) Records Requests regarding all the USFS aircraft Air-to-Ground radio transmission records on the YH Fire; USFS and USDA Office of General Counsel (OGC) emails regarding the possession and status of the AFUE records and contained in a "3-ring binder;" USFS and USDA direction on the AFUE records, USFS employees talking about the YH Fire; Wildland Fire Safety Training Annual Refresher (WFSTAR) Weather Channel video by then WLFLLC Manager Britt Rosso sharing his thoughts on discussing and talking about the YH Fire and the GMHS; hearsay exception testimony from Agency employee conversation with GMHS Asst. Foreman Jesse Steed on the morning of June 30, 2013; Sun City West FD FFs photos and videos of June 30, 2013, aggressive fire behavior in the 1624 (4:24 PM) time period and several crossfade YouTube videos of the same by WTKTT; excerpts from the "Our Investigation - Our Truth" podcast talking about a "backburn" [firing operation]; creating and maintaining defensible space; 18 USC criminal codes regarding Federal records management and handling of records, including violations for concealing and / or destroying records; some interesting and informative AZ Republic articles, photos, and tweets posted as a Pulitzer Prize series, including alerting the Wickenburg hospital about the possibility of several injured firefighters; You Tube video clips of YH Fire IMT and misc. WF supervisors personnel radio transmissions pertaining to the Sesame Street and Shrine Corridor area likely firing operation and observed fire behavior; discussions about wildland fire topography (saddles) and fire behavior (fluid dynamics and Venturi effect); and several human factors quotes.
Figure 26. PDF JPEG image of the Actions and Decisions & Orwellian Doublespeak - Coordinated Response Protocol (CRP) and Learning Review from Saddleback Tree Fatality Learning Review - Section 7.1 Introduction - p. 28 (USFS Modoc NF - CA) Source: USFS
The above Orwellian Doublespeak posted above as a PDF JPEG image comes from the USFS Modoc NF Saddleback Tree Fatality Learning Review. What follows is a key example of the word manipulation that your alleged "Investigators" are up to on a Learning Review of the fatal Saddleback Fire Tree Fatality where a Smokejumper was killed on the Modoc NF in Northern California on June 10, 2013..
( httpd://www.wildfirelessons.net/orphans/viewincident?DocumentKey=3f6ac7f6-2dc7-4403-b54c-049fb6610403 ) You will need to copy and paste this link to access the Learning Review and / or Google search the details.
Please think about these bold and assertive Learning Review statements that follow. I think most readers would agree that these two individual words "actions" and "decisions" are clearly two separate and distinct words with two separate and distinct meanings. Right? Yet, this CRaP (I took some liberties here) bunch wants us to believe that "the difference between [them] could not be separated" and by merely placing a vertically diagonal slash (" / ") between the two words in the report made it acceptable as separate words individually or a "combination of both" words together. Furthermore, they go on to boldly assert matter-of-factually that the separate and distinct words "actions" and "decisions" are "consequences and not causes."
The authors confidently argue that this ongoing, unsettling word and truth manipulation has occurred with all wildfire SAIT Reports, Reviews, and the like where WFs were killed by fire - all the way back to the Mann Gulch Fire on the USFS Helena NF near Helena, Montana in 1949 where 12 Smokejumpers and one WF were killed by wildfire.
“To respect words and their conveyance of reality is to show respect to the very foundation of U. To manipulate words is to seek to manipulate truth and to instead choose falsity and illusion over reality. The manipulation of words is itself a violent act. …” (emphasis added) (Cummins and Pieper)
Source: Cummins, M. (2011) Words: Pieper’s “Abuse of Language, Abuse of Power.” The Alternative Path
( https://thealternatepath.org/2011/05/25/words-piepers-abuse-of-language-abuse-of-power/ )
In addition, the English, Political author George Orwell referred to the above as an "instrument for ...concealing or preventing thought" and that "Political language ... is designed to make lies sound truthful." ... He went on to state that "It becomes ugly and inaccurate because our thoughts are foolish, but the slovenliness of our language makes it easier for us to have foolish thoughts. (emphasis added)
"Orwell refers to these words as "meaningless words" and goes on to state: "It is often easier to make up words of this kind ... if thought corrupts language, language can also corrupt thought. ... A bad usage can spread by tradition and imitation even among people who should and do know better." Orwell cautions that "This invasion of one's mind by ready-made phrases ... can only be prevented if one is constantly on guard against them, and every such phrase anesthetizes a portion of one's brain." (all emphasis added)
It all reeks of the insidious term "Doublethink" he describes in his novel "Nineteen Eighty-Four." Orwell continues: "Simply put, doublethink is the ability to hold two contradictory ideas in one’s mind at the same time. ... To know and not to know, to be conscious of complete truthfulness while telling carefully constructed lies, to hold simultaneously two opinions which cancelled out, knowing them to [be] contradictory and believing in both of them ... This demands a continuous alteration of the past, made possible by the system of thought which really embraces all the rest, and which is known in Newspeak as doublethink. ...Moreover, doublethink’s self-deception allows [those in control] to maintain huge goals and realistic expectations: ... Since 1949 ... the word doublethink has become synonymous with relieving cognitive dissonance by ignoring the contradiction between two world views—or even of deliberately seeking to relieve cognitive dissonance. ..." (all emphasis added) Source: George Orwell Politics & the English Language (1946)
With regard to the Figure 26 (above) Orwellian Doublespeak issues addressed, here are a couple of verification sources below, with quotes.to debunk the "actions and decisions are consequences, not causes" falsehood.
"Research shows that people infer the time of their actions and decisions from their consequences."
"Consequences are the outcomes, or results, of your actions and decisions." (emphasis added) Source: Matute, H. et al (2017) Learning to infer the time of our actions and decisions from consequences. Consciousness and Cognition, 56
"When the unintended consequence of a decision is favorable, there is never an issue. The favorable outcome is considered a bonus. When the unintended consequence is adverse, depending on its impact, the decision-making process is questioned, as is the leader who made the decision. (emphasis added)
"In both of these cases (ignorance and error), leaders make decisions on issues without considering the unintended consequences, or before needed information is obtained. These are decisions that are not well thought out nor operationalized. (emphasis added)
"Immediacy of interest: where “someone wants the intended consequence of an action so much that he purposefully chooses to ignore any unintended effects,” to the peril of the decision maker and the organization. Hubris is one cause and is defined as excessive pride or self-confidence, arrogance." (emphasis added)
"Consequences and Responsibilities"
( https://1.cdn.edl.io/1j8nZHcQ3Y2KPU1gvCOeeOVj0S9Nvkj1reArW3X9yjWbdpVy.pdf )
Consider below the photos of Glendale FD patrol rig in Figure 27 (1556 - left) in Yarnell and unknown vehicle (1645 - right) on June 30, 2013, looking at respective increasingly aggressive fire behavior.
Figure 27. PDF JPEG images of June 30, 2013, 1556 (3:56 PM - left) in Yarnell from the Ranch House restaurant parking lot along Hwy. 89 and 1645 (4:45 PM - right) outside Yarnell near the Model Creek school area in Peeples Valley respectively, revealing WFs and FFs and their associated vehicles with increasing aggressive fire behavior and associated large smoke columns (plumes) in the background. The right photo reveals the GMHS burnover occurring in their deployment site. Source: PVFD
I question the intensity of the fire behavior observed in the Figure 27 (left) time of 1556 (3:56 PM). This detail may need to be examined further to determine if the camera setting was accurate and / or the metadata is accurate.
FIGURE 27 CORRECTION NOTICE: One of our contributing (non-local) authors incorrectly posted in our Washington, DC PowerPoint presentation captions that the direction the viewer is looking in the right photo is West. A Google Earth fact check revealed that the respective photographer, near the Model Creek school area in Peeples Valley, was actually facing in a Southeasterly direction. We apologize for any confusion or consternation this may have caused. Refer to Figure 27a Snippet below.
Figure 27a. Google Earth street-view image Snippet of approximately where the June 30, 2013, 1645 (4:45 PM) photograph was taken from next to the Model Creek school area outside Yarnell. The photo was taken from the vacant land next to the Model Creek school. The view is looking Southeasterly if you were standing where the photo was actually taken. Source: Google Earth
Therefore, the pair of photos in the Figure 27 AHFE PowerPoint presentation PDF JPEG image above reveals the Yarnell Hill Fire (YH Fire) scene on June 30, 2013, at the Ranch House restaurant parking lot (left) in Yarnell, AZ along Hwy. 89 and in Peeples Valley (right) near the Model Creek school area outside Yarnell, respectively. These photos reveal numerous WFs, FFs, and likely citizens as well, and their associated vehicles witnessing increasingly aggressive fire behavior with associated large smoke columns (plumes) in the background. Based on the time, the right photo reveals the fire behavior as the Granite Mountain Hot Shots (GMHS) fatal burnover is occurring in their deployment site.
Emphathetically, in both of the photos below in Figures 28 and 29, you readers can only imagine what we (two eyewitness hikers) experienced along with these WFs, FFs, reporters, and others are experiencing, thinking about, talking about, discussing internally and with others while they frustratingly listen to and anguish over the Tactical and Air-to-Ground radio transmissions of the GMHS, obviously in deep trouble, and then wondering - yet wanting to deny what they know is occurring - what they know from experience the final outcome will be.
Figure 28. PDF JPEG images of June 30, 2013, 1645 (DSC01159.JPG - 4:45 PM - left) and 1648 (4:48 PM - right), respectively showing WFs and FFs and supervisors and their associated vehicles, in the Ranch House restaurant parking lot off Hwy. 89 in Yarnell, AZ with noticeably more aggressive fire behavior in the background (right). Both photos reveal fire behavior at the time that the GMHS burnover was occurring while in their deployment site. Source: PVFD (left) and Michelle Lee (right)
Figure 29. PDF JPEG image of June 30, 2013, 1712 (5:12 PM) from Ranch House restaurant along Hwy. 89 in Yarnell. Smoke columns (plumes) visible in the background with WFs and FFs likely discussing what to do next and what just occurred with the GMHS burnover in their Deployment Zone. Source: Tom Story
Figure 30. Wildland Fire (WLF) LLC "Honoring the Fallen" November 2014 video talking about the June 30, 2013, YH Fire Source: WLFLLC and YouTube
"In the land of the blind, the one-eyed man is King." Erasmus of Rotterdam This saying basically means that someone with even the slightest bit of vision or wisdom or knowledge could guide those who are ignorant or blinded from the truth, (i.e. the WLF LLC).
"Not many of you should become teachers ... because you know that we who teach will be judged more strictly." James 3:1.
Honor The Fallen - Wildland Fire Lessons Learned Center (LLC) - October 2018
( https://wildfirelessons.wordpress.com/2018/10/23/honor-the-fallen/ )
The Wildland Fire LLC in the website link above asks a rather serious thought provoking, and somewhat disturbing question, and then they answer it somewhat ambiguously and equivocally making it tough to relate to and understand (posted below). They then challenge us to question our long held beliefs. Of course, we provide our responses, sometimes agreeing in total, sometimes in part, and sometimes challenging their challenges to us. Foremost, this is our First Amendment right and it is squarely in line with the WLF LLC Mission Statement: "To promote learning in the wildland fire service by providing useful and relevant products and services that help to reveal the complexity and risk in the wildland fire environment.".
"How exactly do we Honor the Fallen?" - "It's a tough question because it has a thousand answers. One of the most important ways to honor is to learn. We are always in danger of squandering the bitter opportunity that tragedy affords us." (emphasis added)
Absolutely, I agree that one of the most important ways to honor is to learn. However, what are we learning? Are we learning the truth about what happened and why? Or are we learning what the alleged "Progressive Thinkers" and detractors opposed to what works and those that want us to think that is solely and strictly within the confines of the SAIT-SAIR and nothing else?
The WLF LLC states: "This video is a glimpse of what many of us struggled with in the aftermath of the Yarnell Hill Fire. This is just a few fire folks walking the ground in January 2014 and grappling with how to advance our culture in the aftermath of devastation. ... Take a look, ... Making sense of bad outcomes is difficult, often impossible. ... But nobody wants the pain to be without benefit. ... Suffering without growth is tragic. ... Let's chose growth. ... One way to grow is to challenge long held beliefs." (emphasis added)
"One way to grow is to challenge long held beliefs. (emphasis added) This could be a true statement, however, the truer statement - from the alleged Wildland Fire Lessons Learned Center - might be better interpreted and understood as utilizing those validated, tried-and-trued long held beliefs as "complete" lesson learned to be shared with other WFs, FFs, and those wanting to comprehend and understand.
"What are some of your long held beliefs? ... Are you willing to question them? ... Are you willing to consider a new perspective? ... And after all that, are you willing to actually alter your actions? ... Growth is difficult." (all emphasis added)
Apparently, this line of questioning is wholly based on the fact that these "few" WLF LLC "fire folks" strongly believe the SAIT-SAIR conclusion of "no indication of negligence, reckless actions, or violations of policy or protocol" and that the entire YH Fire debacle and GMHS tragedy was an accident, just one of those things that happens, of whatever excuse they want to posit to square with the "no blame and no fault" way of thinking.
"What are some of your long held beliefs?" ... I believe in Almighty God and the power of Jesus and the Holy Spirit. I believe in the strength and veracity of the tried-and-trued Rules of Engagement and the principles of Entrapment Avoidance. (e.g. Ten Standard Fire Orders, LCES, and the Watch Out Situations) There has never been a wildland fire mishap - by fire - when adhering to the Basic WF Rules.
"Are you willing to question them?" ... First off, why do I need to question them? They work and always have! I am NOT willing to question them. However, I am always more than willing to discuss them, defend them, and debate them if need be.
"Are you willing to consider a new perspective?" ... What is wrong with the "old" perspective that we need to question it? I am willing to consider a new perspective only if it enhances and /or improves upon the "old" perspective.
"And after all that, are you willing to actually alter your actions?" ... After all that, I am NOT willing to actually alter my actions, unless it enhances and /or improves upon the "old" perspective as stated above.
"Growth is difficult." Growth can be difficult, but not always, and it doesn't necessarily need to be.
These are the self-same individuals that, almost immediately after the YH Fire Serious Accident Investigation Team (SAIT) was in place and certainly after the SAIT Serious Accident Investigation Report (SAIR), that were part of the intensive movement by many of the YHF SAIT members, Subject Matter Experts (SMEs), and select U.S. Forest Service (USFS) personnel to discredit the tried-and-trued "10 & 18" as well as the and the Rules of Engagement and principles of Entrapment Avoidance discussed elsewhere by former USFS Fire Director Jerry Williams. USFS Jerry Williams FMT link ( https://www.fs.fed.us/sites/default/files/fire-management-today/62-4.pdf )These so-called, self-proclaimed experts believe that they are the only true guardians of what is to be discussed and believed of the tragic June 30, 2013, YH Fire wildland fire fatality truth and knowledge as published in the SAIT-SAIR. In other words, the "Party Line." They visited USFS Ranger Districts during their Critical Training sessions, Wildland Fire Training Academies, Wildland Fire Apprenticeship Academies, and many other forums to discredit the "Old School" ways as being ineffective "because 19 men died" - to focus only on the "official" and "factual" SAIT-SAIR for information and guidance.
The Wildland Fire Lessons Learned Center (WLF LLC) YouTube video above states disingenuously that "This video was captured on site of the Yarnell Hill Fire in January 2014. The participants spent the day walking the ground and discussing the challenges facing the wildland fire service as a whole." (emphasis added) On the contrary, these were views discussed among and by themselves and NOT the wildland fire service as a whole, as they boldly claimed. These "progressive thinkers" say they want to protect their "Brothers" by "honoring" them in the process. And yet it is clear that they want to hide or obscure the facts of what transpired and why on the June 30, 2013, YH Fire - while insisting that these wildland fires are "too complex" and that we cannot do this alone anymore, that it basically takes the whole fire community because "no one individual or unit" is capable of that any longer, worst of all, from the USFS Program Manager for the National Apprenticeship Program, that the Basic WF Rules, the "10 and 18" no longer work and that we should instead have "luck decision conversations."
"Although we need the Word to keep things known in the common, people still treat specialists as if their nonsense were a form of wisdom." Heraclitus’s Fragments: Ancient Wisdom for a Changing World ( https://fs.blog/2013/10/heraclitus-fragments/ )
Even from circa 500 BC, Heraclitus’s advice is still valid because dangerously and disconcertingly, it is the unwary and trusting-without-verifying WFs and FFs that will treat these WLF LLC "specialists as if their nonsense were a form of wisdom."
This seems like a good segue to address the causal human factors as to the why question so many of us struggle with; why the GMHS did what they did is covered in this book by German psychologist, researcher, and author Dietrich Dorner (The Logic of Failure - 1998). They were most familiar with and fell right in line with what he remarkably concludes as being habitual: “... the violations of safety rules were by no means ‘exceptions’ committed for the first time. They had all been committed before – if not in this precise sequence – without consequences. They had become established habit in an established routine. The operators did things this way because it was the way they had always done them before.” (emphasis added)
A link follows for an excellent collection of short statements from Dietrich Dörner's The Logic of Failure: Recognizing and Avoiding Error in Complex Situations. Obviously, it falls far short of a viable substitute for reading and studying his book. The data collected in the many participants' own words show how people fail in their thinking and what behaviors aided them in understanding “dynamic systems” and thinking effectively and proficiently. ( http://cjbibus.com/STCT_DornerquotationsWhole.htm )
Consider now a couple of recent WLF LLC posts titled: Has Nothing Changed? and What We Learned from the Yarnell Hill Fire Deaths (November 2018) Has Nothing Changed? November 1, 2018 / wildfire lessons - By Wildland Fire LLC Travis Dotson
( https://wildfirelessons.wordpress.com/2018/11/01/has-nothing-changed/ )
Pay particular attention to the insight of commenter "alex" who obviously speaks from experience, with some authority, with a fair amount of knowledge about the YH Fire debacle, the GMHS tragedy, working around / with some Hot Shot Crews, and the causal human factors that is counter to the SAIT-SAIR. Kudos to you "alex" and thank you for speaking your mind and sharing your thoughts.
"What We Learned from the Yarnell Hill Fire Deaths"
alex - November 2, 2018 at 10:05 am
"What we learned from Yarnell Hill. As an industry we learned that Arizona state OSHA and the Arizona Dept. of Forestry have very different interpretations of what needs changed and who might be to blame. We also learned that absolutely no one knows what actually happened. By now we have learned that people want to put a sticker on their hardhat, lament the tragedy and pretend like it never happened." (emphasis added)
On the contrary, there are plenty of WFs and FFs and Supervisors that were there that day that know exactly what actually happened ... and why.
And they "know exactly what actually happened" that day, and that include yourselves - those reading this post. You do know exactly what happened, you just don't exactly know why! “They were just firefighters. This is not what they were trained [to do]. Hotshots are never “just firefighters”. Hotshots are the elite of firefighting. They answer to no one below a division supervisor on the hill, they make decisions affecting the entire fire, they communicate with adjoining resources when they deem it necessary, they are completely independent of the fire to the point that they don’t even stay in camp with the 'just firefighters'. All of this culminates into a culture of machismo and elitism so strong that 19 people died and no one has any clue why they moved, where they were going or even what their intention was. How is it that we have hundreds of people operating on the line every day who have no accountability and are given such amazing leeway to make whatever decision they want without any outside input that 19 people died with the entire fire thinking that they were in a safety zone up to the moment they futilely tried to break through the radio chatter to try to get support." (emphasis added)
The guy is actually more on point than he realizes in many respects from the WFs and FFs that engage in wildland firefighting that I have talked to over the years since this tragedy occurred. And the "19 people died and no one has any clue why they moved, where they were going or even what their intention was" is classic GMHS pattern under the GMHS leadership.
"I know that if I took my crew out of a safety zone to march through decadent brush, without communicating with anyone, on a day when shifting, strong winds were expected. If I survived, I would be prosecuted." (emphasis added)
Prosecuted may be a bit much but chastised for sure. And more than likely you would not do that nor hopefully, have you done that.
"The fire culture of elitism allows crews to operate with no oversight and little accountability as long as the word “hotshot” is written across their vehicles." (emphasis added)
There is some truth to his claim about the fire culture of elitism allowing crews to operate with no oversight and little accountability as long as the word “hotshot” is written across their vehicles.
"This isn't about the inherent danger of the industry." (emphasis added)
Except for the Draconian punishment for foolishly marching through decadent brush without communication during strong winds, alex once again, is more on point than he realizes. It is a rather foolish and quite dangerous habit to hike through the unburned that fits right into the "Normalization of Deviance" and the "Bad Decisions With Good Outcomes" category worthy of some serious correction. And prosecuted for sure for being responsible for killing your men.
Whether alex or anyone else likes it or believes it or not, it really is "about the inherent danger of the industry" because wildland firefighting in general and Hot Shot Crews in particular, are key components of the wildland fire industry; so they are just gonna have to get over it and deal with it ... unless they want to be a part of changing it in order to reduce WF and FF wildfire fatalities.
alex - November 21, 2018 at 10:43 am "Please forgive me if this comes off as argumentative or insensitive. The impression that hotshot crews operate independent of instruction comes not only from decades of working next to them but also from the fact that 19 of them died and even now, no one has any idea what they were doing or why they left the safety of the black. Yes Eric Marsh was assigned as the Div. Sup. and this led to even less communication outside of that crew and no oversight whatsoever as the only overhead assigned to supervise that was part of the crew. Obviously the plan formulated by boots on the ground was bought (sic) into by the Div. Sup. because he was a crewmember and probably helped to create it. This is not independent? Who did he run that plan by that was his supervisor?" (emphasis added)
As stated above, on the contrary, there are plenty of WFs and FFs and Supervisors that were there that day that know exactly what they were doing. And a pretty good "idea why they left the safety of the black." And that includes yourselves - those reading this post. For one, no one held a literal gun to their heads and forced them to leave the black. They left of their own free will. Figuratively, they may have succumbed to the "perception is reality" fallacy so often bandied about and therefore, they may have felt emotionally compelled to obey an unsafe order.
Under stress, perception can have the force of reality. Make reality the reality."The point that I am trying to make is that while hotshots may be “problem solvers” or “the tip of the spear” ,they are still given more latitude than any other resource outside of smokejumpers. This is viewed as carte blanche to operate any way they feel. I have personally seen the results of this in having backburns lit under my crew by hotshot crews that no one knew were in the area, having aerial resources currently In (sic) use redirected by hotshots without any communication whatsoever, having hotshot supervisors give direction to my crewmembers without any recognition of chain of command and literally countless times that my crew has had to work adjacent to them only to have them pretend like we didn’t exist and I receive nothing but condescension, disdain and impatience from the supervisor when I make an attempt to communicate with adjoining resources (talk to the hotshots). Nothing has changed in regards to this behavior. I received that exact condescension, and disdain this season even." (emphasis added)
Once again, Mr. alex is actually more on point than he realizes in many respects from the WFs and FFs that engage in wildland firefighting that I have talked to over the years concerning his views on HS Crews, albeit somewhat jaded or maybe just experienced.
"Nowhere is this more obvious than the example of Yarnell. 19 people died, no one has any idea what they were doing or where they were going. There was no attempt to inform anyone of their movements or their intentions. No one seems to find that strange. It’s just part of how hotshots operate.. Where I work, operating adjacent to a hotshot crew is the 19th watchout situation." (emphasis added)
On the contrary, there are plenty of WFs and FFs and Supervisors that were there that day that do, in fact, have many ideas what they were doing and where they were going. And their Watch Out #19 is Death From Above includes overhead because after all, they are known to make bad decisions from time to time, (i.e. Holloway Fire 2012).
"There was no attempt to inform anyone of their movements or their intentions" is very accurate because that is the way the GMHS were known to do things. The same applies to the WFs and FFs performing the likely Sesame Street and Shrine Corridor area firing operation." (emphasis added)
There were many Structure / Municipal FFs, often referred to as "Hybrids," on the June 30, 2013, YH Fire that performed quite well. And there were others not so much. These "others" may have been the ones involved with the likely firing operation. And the fact that alex use the colloquial term "backburn" reveals to me that he (or she) is possibly a "Hybrid" FF and not a "real" WF. As stated above, on the contrary, there are plenty of WFs and FFs and Supervisors that were there on the YH Fire that fateful that day that knew exactly what they were doing and where they were going; and none of them were entrapped, deployed fire shelters, or died.
( https://wildfirelessons.wordpress.com/2018/11/01/has-nothing-changed/ )
Figure 31. WLFLLC "Honoring the Fallen" video. Pockets of progressive thinkers” Fireline Leadership program, Wildland Fire Lessons Learned Center (WLFLLC), USFS Washington Office (WO), USFS Apprenticeship Program talking about the Yarnell Hill Fire and deriding the Basic WF Rules, i.e."10 & 18" (4:05 to 5:57) Source: Wildland Fire LLC
"The truth is … we … put it into these little boxes … these rules and the 10 & 18 that cannot, … they're not gonna keep us safe, that's been proven time and time again, … whatever they are, … cannot follow our own rules … this environment way too complex … need to have luck decision conversations … it was good ... until it wasn't ...” Heath Cota (USFS - Director Wildland Firefighter Apprenticeship Program - S&P-WO, Fire & Aviation Management) courtesy of the Wildland Fire Lessons Learned Center (LLC) - Honor the Fallen - YH Fire site visit in January 2014 - YouTube video published October 23, 2018. (emphasis added)
( https://www.youtube.com/watch?v=TE6Rfa3Vuo0&t=6s )
Are you kidding me? This is coming from the National Director of the USFS Wildland Firefighter Apprenticeship Program [WFAP] - S&P-WO, Fire & Aviation Management ... the ones that train our up-and-coming new USFS career-based employees, the future of the wildland fire culture! From their own website we learn the following:
"Vision To develop and enhance today’s wildland firefighters with the skills, knowledge and abilities to perform as tomorrow’s competent and effective leaders. Operational Mission - Delivering innovative and fundamental training for the development of wildland firefighters, utilizing a highly skilled and motivated team. The Wildland Firefighter Apprenticeship Program is registered as a part of the National Apprenticeship Program in accordance with the Department of Labor, designed to enhance and develop future Fire and Aviation Managers. The intent of the Program is to take career entry firefighters and provide a hybrid of education, training and paid work experience of 3,000 hours. The WFAP delivers innovative and fundamental training for the development of wildland firefighters. ...This is a great program if you’re interested in making wildland firefighting a career!" (emphasis added)
More than you ever wanted to know about the National Wildfire Apprenticeship Program (WFAP) and how it's training up and enlightening the Nation's new WFs ( https://www.nafri.gov/wfap/manager.php )
Check out page 24 for the training electives - Human Performance, Leadership, Lessons Learned, Fire and Aviation Management Operations. Electives are optional courses, yet tend to be more specialized, so discretionary for each student. According to the majority of educational literature, electives (1) allow you to explore other subjects and areas of study; (2) may give you a new perspective on your degree and your future career path; (3) may make you more attractive to potential employers; (4) may expand your educational horizons, giving you insight into other categories or increasing your overall thinking and learning skills; (5) and lastly, may help you to build strong core values that will help you in achieving your desired degree and being successful in your field. (emphasis added)
The USFS appears to have its own subtly covert agenda when it comes "to enhance and develop future Fire and Aviation Managers" regarding wildland fire fatalities and mishaps, and the (in)complete lessons to be garnered and the potentially meaningful lessons to be learned from. Unfortunately, history has revealed that they squander those choice opportunities to share the truths about what happened and why, again and again.
Below are several of the course offerings and some detail with my comments in green:
Lessons Learned - This course will focus on lessons learned from the previous fire season as well as other historic incidents to ensure that students are learning from the past and applying these lessons throughout their career. (N-9053 Learning From Unintended Outcomes), 40 hours - Formal staff rides, maximum of 20 hours (emphasis added)
I find it ironic that they spend 40 hours on the Learning From Unintended Outcomes training course and "a maximum of 20 hours" on "Formal Staff Rides." So the take away here is more time on how to "investigate" (or not) or perform no blame, no fault "Learning Reviews" instead of more realistic on site Formal Staff Rides. In other words, spending twice the amount of time on investigating or not finding blame or fault and half the time on valuable Formal Staff Rides. However, it may be that the final outcome may be the same because the SAITs and /or FLAs, RLAs, Learning Reviews, etc. are false because they are based on first establishing a "conclusion" and then finding the "facts" to fit the pre-established conclusion. And the Staff Rides are then based on these false, preconceived conclusions, so the false narrative continues without any "complete lessons learned" as pointed out by Dr. Ted Putnam and Dianne Vaughan, the Columbia and Challenger researcher and author.
"N-9053 Learning From Unintended Outcomes - The Facilitated Learning Analysis (FLA) and Coordinated Response Protocol (CRP) are group learning approaches to review a broad spectrum of unintended outcomes or close calls ranging from fatalities and escaped fires to vehicle accidents. Through lectures, case studies, and interaction between participants and faculty, the course will: Illustrate concepts, technologies and methods to actively engage the FLA and CRP processes. Examine case studies that describe a paradigm shift from blame to learning in the wake of an accident.(emphasis added)
"Demonstrate the use of storytelling to exploit accidents and other unintended outcomes as learning events. ... Underline the concept of sense-making to enable FLA and CRP team members to overcome hindsight bias. ... Move organizations towards a learning culture. ... Prepare participants to serve as FLA and CRP team members. ... Personnel interested and available to participate on review teams analyzing all types of accidents and near-misses. ... The Workshop participation is not limited to Fire and Aviation Management employees. ... Nationally recognized subject matter experts serve as instructors in this course. (emphasis added)
The above paragraph is rife with statements worth commenting on and critiquing. Obviously, the use of storytelling is a worthwhile goal, if and only if, the goal is to tell the truth about what happened and why. And to want to "exploit accidents and other unintended outcomes as learning events" has kind of a negative connotation using the word "exploit." The "concept of sense-making" is definitely a worthwhile goal "to overcome hindsight bias" as well as "mov[ing] organizations towards a learning culture." However, I feel that it is dangerous to "Prepare participants to serve as FLA and CRP team members. ... Personnel interested and available to participate on review teams analyzing all types of accidents and near-misses. ... The fact that there are nationally recognized experts [that] serve as instructors in this course" is questionably valuable considering that they likely have a wealth of experience and knowledge, however, these Steering Committee members are, for the most part, former "Investigators" on previous SAITs, FLAs, RLAs, and Learning Reviews that concluded everything but "factual" information toward what we need - "complete lessons learned."
"Prerequisites: None, However preference will be given to individuals with experience in risk management, safety management and accident investigations. Staff Ride, Rattlesnake Fire / Lessons Learned - Much of the knowledge gained about wildland fire has come through the high cost of firefighter lives. Lessons learned from the Rattlesnake Fire played a large role in the decision to form the first national level task force to examine wildland firefighter safety in 1957. Other staff rides may be used depending on academy location. (emphasis added)
"Risk Safety - Various speakers will discuss and present information about risk in wildland fire and provide opportunities to learn from their personal experiences." (emphasis added)
So basically, my takeaway on the whole USFS Wildland Firefighter Apprenticeship Program [WFAP] that is responsible for training our up-and-coming new USFS career-based employees, the future of the wildland fire culture - is a guaranteed means to avoid telling the truth by regurgitating the Facilitated Learning Analysis (FLA) and Coordinated Response Protocol (CRaP) with their N-9053 Learning From Unintended Outcomes course, taught by many of the same players covering stuff up. Note the difference in hours here: 40 hours for the FLA and CRaP courses, and yet, Formal staff rides, where the most true learning would take place, are only allowed a maximum of 20 hours. In other words, focusing on the process to promote the lies and deceptions holds more weight than sharing the truths in case studies and actual events though Staff Rides.
And then you have this gem wasting our precious tax dollars on this: WFSTAR: Fire Orders NWCG - National Wildfire Coordinating Group (NWCG) with this paid patsy likely having no clue of what WFs and FFs do for a living in the inherently dangerous environment they work in. Worst of all, it is endorsed by the NWCG and very likely one of the many desperate attempts - several years later - to respond to the June 30, 2013, YH Fire debacle and GMHS tragedy. WFSTAR: Fire Orders ( https://youtu.be/bWiuTey03Yc ) Published on Apr 10, 2018.
And here is another link to a National Interagency Fire Center (NIFC) endorsed You Tube video on the "10 and 18." ( https://youtu.be/_-9LKkSDVzE )
Be sure and watch this despicably nauseating video on the Ten Standard Fire Orders endorsed by National Wildfire Coordinating Group and NIFC. Based on the published date, I feel that this is very likely a response by NWCG after the June 30, 2013, YH Fire and GMHS fatalities and therefore, part of the concerted effort to provide some type of feckless answer - several years later - to those preventable tragedies. Time stood still when the Devil ..... is mentioned in the video below.
Yarnell Hill - ( https://youtu.be/eUXp9mTh7P0 ) Matty O - Published on Aug 18, 2019.
" ... as time stood still when the Devil came to Yarnell Hill ... so these heroes that met their fate courageous to the end ... " I'm quite sure this guy means well and is closer than he realizes on his "time stood still when the Devil came to Yarnell Hill" verbiage. The "time stood still" notion is addressed concerning the dreaded "Lunch Spot" scenario that has now occurred on four known wildland fatality fires (e.g. Rattlesnake, South Canyon, Thirty Mile, and Yarnell Hill Fires) in a 2018 AHFE paper titled: "It Could Not Be Seen Because It Could Not Be Believed on June 30, 2013" (Fred J. Schoeffler and Lance Honda) quoted below.
"2.2 Consequences of Inattention - Fatality Fires and ‘Lunch Spot’ Nexus Theory. Additionally, the multi-fatality South Canyon (1994), 30-Mile (2001), and YH (2013) Fires shared a common element when disengaged to a designated Lunch Spot. In this setting, due to numerous physiological and psychological circumstances, (e.g., fatigue, stress, dehydration, alcohol-related impairment (hangovers), distractions, interruptions, etc.) - time essentially stood still.
"In each of these above noted tragic wildfires, when the WFs re-engaged, they were evidently unmindful of basic wildland firefighting training and fire behavior markers which favored staying put. They were so engrossed with “discussing their options” of staying put or re-engaging, they ceased observing more pressing tasks, like the rapidly changing weather. They let go of strategic management for less serious, less vital events, known as strategic omission." (all emphasis added)
"Credible research on attention found when someone is otherwise engaged, at times they fail to “see” otherwise noticeable, fully visible, - yet unexpected objects or events, (i.e. ‘inattentional blindness’ [IB]). A likely severe result is that it can sometimes lead one to miss items that one wanted or, more importantly, needed to experience. If one’s attention is set for a certain number of primary task items and the offered items meet their expectation, the individual may be more likely to exhibit IB for an unforeseen and yet likely critical visual event. IB was driven more by situational and task factors, … than by individual-differences variable. This may help explain some of why the GMHS and others faced and then reacted to this obscure perilous occurrence." (Schoeffler and Honda - AHFE - 2018) (all italics emphasis original - all other emphasis added with citations omitted).
Figure 32. PDF JPEG image of Former Yarnell Hill Fire Chief Peter Andersen (RiP) Interview Oct. 8, 2013 describing the AZ Forestry Division's response to the Yarnell Hill Fire that killed 19 Granite Mountain Hotshots on June 30, 2013. Source: YouTube and John Dougherty
Figure 32a. Former Yarnell Hill Fire Chief Peter Andersen (RiP) Interview Oct. 8, 2013 describing the AZ Forestry Division's response to the Yarnell Hill Fire that killed 19 Granite Mountain Hotshots on June 30, 2013. Source: John Dougherty and YouTube
This is an interview from an experienced - locally knowledgeable (Watch Out #4) - politically incorrect Fire Chief confidently and honestly speaking his mind about that day and the feckless SAIT and SAIR; even validating the Sesame Street and Shrine Corridor area likely firing operation.
Figure 33. PDF JPEG image of Yarnell Fuel Treatment Source: Local FD Records Request. Collura
This document falsely claims: "Reports indicate that this work helped slow the 2013 Yarnell Hill Fire when it crossed Hwy 89 from the north on June 30th." On the contrary, the WFs and FFs that were involved in the likely Sesame Street and Shrine Fuel / Fire Break Corridor area firing operation used it as their control line and actually fired off from it. And therefore, it was their likely burnout and / or backfire that burned across Hwy. 89 from the North into Yarnell and not the fire - naturally. There is a firefighter (unsure if WF or FF) that told me that it never jumped the highway and it was their Crew that lit it. There is also some conflicting testimony from others that said it may have jumped the highway from flying embers. So then, which one is it? Obviously, this needs further looking into.
Figure 34. PDF JPEG image of Inattentional Blindness (IB) discussion when one fails to “see” otherwise noticeable, fully visible, yet unexpected objects or events, i.e. “Friendly Fire” from the Sesame Street and Shrine Corridor area firing operation taking place below them. Source: Schoeffler, Honda, Collura
Credible research by Daniel J. Simmons (Univ. of Illinois Visual Cognition Lab) on (in)attention, referred to as Inattentional Blindness (IB), indicates that "when someone is otherwise engaged - at times - they fail to 'see' otherwise noticeable, fully visible, yet unexpected objects or events." In this exceptional YH Fire GMHS case, it was the increasing fire behavior “Friendly Fire” that was occurring in the likely Sesame Street and Shrine Corridor area firing operation taking place below them. "IB leads one to miss items what one needed to experience, if an event meets their expectation(s). We are also likely to experience IB for a sudden, possible critical visual event." (emphasis added)
Consider now some of the broader Implications of Inattentional Blindness found by researchers.
“Evidence for inattentional blindness comes mostly from relatively simple laboratory tasks, but the phenomenon likely has many daily analogues. For example, automobile accident reports frequently report driver claims that they “looked but failed to see” the other vehicle. Many collisions between cars and motorcycles involve cars turning in front of an incoming motorcycle, with the car driver not seeing the motorcyclist. … Critically, the difficulty of the primary task in an inattentional blindness task increases the probability that people will miss the unexpected object. In practical terms, the more people focus on aspects of their visual world other than the detection of unexpected objects, the less likely they are to detect such objects. Recent evidence suggests that talking on a cell phone, for example, dramatically increases the probability of missing an unexpected object (Scholl et al, 2003).
"Although inattentional blindness constitutes a limit of the visual system, it also illustrates a critical aspect of visual processing. Specifically, it reveals the role of selective attention in perception. Inattentional blindness represents a consequence of this critical process that allows us to remain focused on important aspects of our world without distraction from irrelevant objects and events. Only when those unselected aspects of our world are both unexpected and important does inattentional blindness have practical consequences. ...
"[Researchers] Scholl et al, 2003, concluded that in daily life attention is constantly spread ... across several modalities, tasks, and objects, and it is unclear how attention operates in such realistic situations. Here we report a striking effect of sustained inattentional blindness (SIB) induced by one particularly relevant attention-demanding task: talking on a cellular telephone. Much research has shown that talking on a cellphone will slow responses, increase performance errors, and degrade detailed visual memory. But while some traffic accidents are no doubt caused by such factors, many have a different cause: Why did I hit the other car? Because I didn't *see* it! ... The massive jumps in SIB caused by the cellphone conversations and other cognitively engaging controls suggests a sobering conclusion: that visual *awareness* is particularly impaired by cellphone conversations, above and beyond any smaller effects on visual performance. (all emphasis added)
Scholl, B. J., Noles, N. S., Pasheva, V., Sussman, R.(2003). Talking on a cellular telephone dramatically increases ‘sustained inattentional blindness’ [Abstract]. Journal of Vision, 3( 9): 156, 156a
( http://www.scholarpedia.org/article/Inattentional_blindness )
Based on documented (albeit altered) evidence, the GMHS and DIVS A were certainly involved in ongoing radio and cell phone conversations, as well as one-on-one and / or small group conversations during the June 30, 2013, operational period on the YH Fire in Division A. Therefore, it is a permissible inference that these ongoing radio, cell phone, and likely face-to-face conversations likely adversely influenced their individual and collective ability to cognitively process what they were "seeing." These indicators included the deteriorating fire weather and exponentially increasing fire behavior while failing to "see" that matters were tactically unsafe and unsound for them to vacate their Safety Zone and travel through heavy unburned chaparral through chimneys and chutes down into a deadly bowl; all counter to everything that they had been trained to avoid and to heed in favor of sound tactics.
Figure 35. The YH Fire - 2013 - SAIT-SAIR "Figure 19" helps to clarify the fire activity ( https://youtu.be/Jl1l8EyDric ) (WTKTT) in Figure 33. above. Source: Matt Oss, SAIT-SAIR, YouTube, WTKTT
This crossfade video reveals the fire behavior and resource locations (from metadata) from both the Yarnell side as wll as the Congress side.
Figure 36. PDF JPEG image of questioning of "Securing the scene?" of the GMHS Deployment / Fatality Site documented News Station video evidence of the total lack of scene security and the PFD and others' PACT that they made and NOT to ever talk about what happened that night. The news video later disappeared and a News article changed the word PACT to the phrase "nightlong vigil for the Yarnell 19 is something the firefighters have kept to themselves." Source: AZ Family.com, Internet Archive Wayback Machine