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Part 1b - Do our Wildland Fire (WF) Instructors foster "complete" lessons learned in the WF culture?

Authors - S130 / S190 / L180 Lead Instructor Fred J. Schoeffler and Co-Instructor / SME ( YH Fire ) Joy A. Collura

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Continuing from "Part 1a - Do our Wildland Fire (WF) Instructors foster "complete" lessons learned in the WF culture?"...due to this message when trying to put blog on said I had to break part one into several posts:




Figure 7. The descent of a subsidence inversion may be followed on successive soundings, as shown by dashed lines. As the more humid surface air flows outward, the drier air aloft is allowed to sink and warm adiabatically. Source: Fire Weather Handbook

The inversion will be wiped out only in local areas where surface heating is intense enough to do the job. If the heating is not sufficient to eliminate the inversion, the warm, dry air cannot reach the surface by convection. Convective currents in the layer beneath the inversion may be effective in eating away the base of the inversion and mixing some of the dry air above with the more humid air below. This process will warm and dry the surface layer somewhat, but humidities cannot reach the extremely low values characteristic of a true subsidence situation.

Another method by which dry, subsiding air may reach the surface is by following a sloping downward path rather than a strictly vertical path. A vertical sounding may show that the subsiding air is much too warm to reach the surface by sinking vertically, because the layer beneath it is cooler and denser. However, if surface air temperatures are warmer downstream, the subsiding air can sink dry-adiabatically to lower levels as it moves down stream and may eventually reach the surface. This process is most likely to occur around the eastern and southern sides of a high-pressure area where temperatures increase along the air trajectory. By the time the sinking air reaches the surface, it is likely to be on the south, southwest, or even west side of the High.

Subsiding air may reach the surface in a dynamic process through the formation of mountain waves when strong winds blow at right angles to mountain ranges. Waves of quite large amplitude can be established over and on the leeward side of ranges. Mountain waves can bring air from great heights down to the surface on the lee side with very little external modification. These waves may also be a part of the foehn-wind patterns, which we will touch off only briefly here since they will be treated in depth in chapter 6. In the mountain areas of the West, foehn winds, whether they are the chinook of the eastern slopes of the Rockies, the Santa Ana of southern California, or the Mono and northeast wind of central and northern California, are all associated with a high-pressure area in the Great Basin. A foehn is a wind flowing down the leeward side of mountain ranges where air is forced across the ranges by the prevailing pressure gradient. Subsidence occurs above the High where the air is warm and dry. The mountain ranges act as barriers to the flow of the lower layer of air so that the air crossing the ranges comes from the dryer layer aloft. If the pressure gradient is favorable for removing the surface air on the leeward side of the mountain, the dry air from aloft is allowed to flow down the lee slopes to low elevations. The dryness and warmth of this air combined with the strong wind flow produce the most critical fire-weather situations known anywhere.

Mountain waves, most common and strongest in the West, are also characteristic of flow over eastern and other mountain ranges. When they occur with foehn winds, they create a very spotty pattern. The strongest winds and driest air are found where the mountain waves dip down to the surface on the leeward side of the mountains.

An example of a severe subsidence condition associated with chinook winds, and in which mountain waves probably played an important part, is the Denver, Colo., situation of December 1957. On December 9, chinook winds were reported all along the east slope of the Rocky Mountains in Wyoming and Colorado. Surface relative humidity at Denver remained at 3 percent or below from noon until midnight that day. The Denver observation at 1900 hours showed: Temperature: 60 (°F.), Dew Point: -29 (°F.), Relative humidity: an incredible 1%, Wind direction and speed: West at 22 mph.


The extremely low dew point indicates that the air must have originated in the high troposphere.

Cases of severe subsidence are much more frequent in the western half of the country than in the eastern regions. Moat of the Pacific coast area is affected in summer by the deep semi-permanent Pacific High. This provides a huge reservoir of dry, subsiding air which penetrates the continent in recurring surges to produce long periods of clear skies and dry weather. Fortunately, marine air persists much of the time in the lower layer along the immediate coast and partially modifies the subsiding air before it reaches the surface.

In the fall and winter months, the Great Basin High is a frequent source of subsiding air associated with the foehn winds, discussed above. It is the level of origin of this air that gives these winds their characteristic dryness.

Subsiding air reaching the surface is perhaps less common in eastern regions, but does occur from time to time. Usually the subsiding air is well modified by convection. But subsidence is often a factor in the severe fire weather found around the periphery of Highs moving into the region [east] of the Rockies from the Hudson Bay area or Northwest Canada mostly in spring and fall. It also occurs during summer and early fall periods of drought, when the Bermuda High extends well westward into the country.

Consider now a few wildland fire weather research papers examining the crucial role of Subsidence on wildland fire behavior, revealed as Dry Intrusions and Dry Slots, utilizing WVI, with a look into the Skew-T soundings from those Soaring buffs that depend (life or death) on accurately depicted up and downdrafts.


WEATHER AND FIRE BEHAVIOR INFLUENCING THE 11-12 JUNE 2013 BLACK FOREST COLORADO (USA) WILDFIRE ( https://ams.confex.com/ams/42Broadcast/webprogram/Manuscript/Paper245722/AMS%2042nd%20June%202013%20Black%20Forest%20Fire%202.pdf )


THE INFLUENCE OF DRY SLOTS ON WILDLAND FIRE GROWTH DURING THE 2011 ARIZONA FIRE SEASON ( https://ams.confex.com/ams/10Fire/webprogram/Handout/Paper225272/AMS%202011%20AZ%20wildfires%20influenced%20by%20Dry%20Slots%20In%20The%20U.S.%202.pdf )


Kaplan, M.L., et al (2008) The development of extremely dry surface air due to vertical exchanges under the exit region of a jet streak. Meteorol Atmos Phys ( http://www.mesolab.us/publications%20%28web%29/2008_Kaplan_etal%28MAP_Jet_Streak_and_Fire%29.pdf )



Figure 8. Vertical cross section of simulated Relative Humidity on the June 2, 2002, 1700 UTC (1300 EDT) Double Trouble State Park (DTSP) wildfire. The bright red low RH region would be a dry slot visible in the WVI. Source: Charney et al (2003) The role of a stratospheric intrusion in the evolution of the DTSP wildfire, Figure 6.



Figures 9a. & b. GOES 8 Water Vapor Imagery (WVI) snippet of June 2, 2002, 1445 UTC (10:45 AM - top) and 1745 UTC (1:45 PM - bottom) indicating dry intrusions and dry slots (subsidence) advecting across the DTSP wildfire region. Gold and yellow colors indicate very dry air Source: NOAA Global ISCCP B1 Browse System (GIBBS)





Figures 10. a-c. (a) KALB (Albany County, NY), (b) KCHH (Chatham, MA), (c) KOKX (Upton, NY) June 2, 2002, 12Z (8:00 AM ) Skew-T Soundings all indicating Subsidence Inversions in the 550 to 600 mb range (roughly 15,000' & 20,000') Source: Plymouth State Weather Center


KALB and KCHH generally match at 400 to 600 mb with single digit Relative Humidity values, with like KOKX site values up into the Jet Stream levels at 200 to 300 mb.



Martin, J. (UP) (2015) Skew T’s – How to Read Them. Finger Lakes Soaring Club, Dansville, NY. ( http://flsc.org/portals/12/PDF/Read_Skew_T.pdf )


3. Entrapment Avoidance 


Use training and reference materials to study, understand, and adopt the risk management process as identified in the Incident Response Pocket Guide (IRPG), PMS 461, as appropriate to participants, (i.e., LCES, Standard Firefighting Orders, and the Watch Out Situations). Entrapment avoidance and deployment protocols are identified in the IRPG, which also contains the “Last Resort Survival Checklist.”


Another good source for specific case studies - with a caveat - is the Wildland Fire Lessons Learned Center (LLC), Incident Reviews Database.

( https://www.wildfirelessons.net/home ) Search by Fire Name, Match Terms, Incident Year, Incident Type (i.e. "entrapment"), fire name, and Incident Location. And the caveat is, of course, the indisputable fact that any and all Serious Accident Investigation Reports and / or Reviews are considerably more fiction-based. That has become - and is - such a regular business practice, and such a minor detail, in their eyes, that those alleged 'Investigators' first decide on a "conclusion" and then find those specious "facts" to support their predetermined conclusion.


Or as one of the former (acting) SW Region Fire Directors stated at a Fire Mgmt. meeting - "There is a grain of truth in everything I say ..." - when he was attempting to evasively avoid telling us what really happened on the fatal April 22, 1993, Santa Fe NF Buchanan RX Burn Fatality where Jemez Pueblo WF Frankie Toldeo was killed due to overly aggressive Aerial Ignition Induced Fire Behavior. The fire behavior was so intense it burned the boots off his feet. Where 16 WFs were entrapped and deployed fire shelters and five WFs suffered minor burn injuries.


When WFs returned from that assignment, they were visibly scared because the cowardly and nefarious "they" were looking for Scapegoats.


Figure 11. WLF LLC Incident Reviews Database, search terms, match terms, incident year, incident type, incident location drop-downs Snippet. Source: WLFLLC


PREMORTEM EXERCISES

Premortem exercises are very powerful tools that begin by looking at an incident that will take place in the near future. All participants are instructed to assume that something went spectacularly wrong and are then asked to determine the cause of this tragic ending, and identify ways of preventing this failure from happening.


Premortem exercises:


Can be done on a scheduled prescribed fire or in an incident action plan (IAP).


Let all participants introduce their idea of what went wrong. Supervisors invite subordinates to tell them how this incident or plan can fail. Look for blind spots.


Determine ways to prevent this failure.




NWCG 6-Minutes for Safety - Escape Routes 1 (Take 5@2)

( https://www.nwcg.gov/committee/6mfs/escape-routes1 )



A. Leadership

Figure 12. NWCG Leadership categories Source: NWCG


Be better able to “speak truth to power” (respectful interaction).


Be able to incorporate new concepts into their daily language.


Recommended Reading List on HRO

Beyond Aviation Human Factors, Daniel E. Maurino, et al.


Managing the Risks of Organizational Accidents, James Reason


Managing the Unexpected, Karl E. Weick and Kathleen M. Sutcliffe


New Challenges to Understanding Organizations, Karlene H. Roberts


Normal Accidents, Charles Perrow


The Limits of Safety, Scott D. Sagan



Taken from a Farnum Street article, consider now some very sage advice from Michael Abrashoff, who became Commander of USS Benfold at age 36, making him the most junior commanding officer in the Pacific Fleet on a ship that was plagued by low morale, high turnover and abysmal performance evaluations. He became a leadership and teamwork expert. In his book, It’s Your Ship, he wrote: The most important skill a skipper can have is the ability to see through the eyes of the crew.(all emphasis added throughout entire article)


"Leaders must free their subordinates to fulfill their talents to the utmost. However, most obstacles that limit people’s potential are set in motion by the leader and are rooted in his or her own fears, ego needs, and unproductive habits. When leaders explore deep within their thoughts and feelings in order to understand themselves, a transformation can take shape."


" ... our company’s purpose is profit. But we will achieve neither by ordering people to perform as we wish. Even if doing so produces short-term benefits, the consequences can prove devastating.


I QUESTION SOME OF THIS ADVICE FROM A WFs PERSPECTIVE -

"Organizations should reward risk-takers, even if they fall short once in a while. ... Stasis is death to any organization. Evolve or die: It’s the law of life. Rules that made sense when they were written may well be obsolete. Make them extinct, too."


We are okay with taking risks - calculated risks - solidly based following the Risk Management process in the IRPG, in our "inherently dangerous" world. However, taking risks and 'rewarding risk-takers,' just for the sake of taking risks is foolhardy and dangerous. And our Basic WF Rules and Guidelines "made sense when they were written" and still make sense, so they are faraway from being "obsolete." The plans to "make them extinct" are only in the minds of those that drink / drank / will drink / encourage you to drink the YH Fire SAIT-SAIR Kool-Aid and believe in and follow the Coordinated Response Protocol and Learning Review subscribe to their conclusion.

Where there is no counsel, the people fall;

But in the multitude of counselors there is safety. Proverbs 11:14 (NKJV)


Consider now the August 7, 2014, Wildfire Today article titled: "USFS to use new serious accident review system" ( https://wildfiretoday.com/2014/08/07/usfs-to-use-new-serious-accident-review-system/ ) and the August 19, 2015, USDA article titled: "The Coordinated Response Protocol and Learning Review for serious accidents" ( https://www.fs.usda.gov/rmrs/science-spotlights/coordinated-response-protocol-and-learning-review-serious-accidents )


The CRP article is ever-so-pleasantly explained; why would there be any reason to shy away from it? "Different investigations are required by USDA Forest Service and by federal regulations following a wildfire-related fatality. Personnel conducting data collection for these investigations might become so focused on their task that they can, inadvertently, be insensitive to persons directly affected by the accident. The Coordinated Response Protocol (CRP) and Learning Review are designed to make the process as painless as possible for all involved." (emphasis added) What f**king BS! One of the three big lies is "Trust us, we work for The Government and are here to help you."


There are no "federal regulations following a wildfire-related fatality" mentioned in this article dealing specifically with "Wildland firefighter deaths in the United States": "Butler, C. et al (2017) Wildland firefighter deaths in the United States: A comparison of existing surveillance systems. J Occup Environ Hyg., 14"


I digress ... Commander Abrashoff discovered that '... exit surveys, interviews conducted by the military to find out why people are leaving" revealed surprising results. ... The top reason was not being treated with respect or dignity; next was being prevented from making an impact on the organization; third, not being listened to; and fourth, not being rewarded with more responsibility. (emphasis added)


Thus Abrashoff came to the conclusion that the best thing he could do was see the ship through the eyes of the crew. This makes it much easier to find out what’s wrong and help people empower themselves to fix it.


"I began with the idea that there is always a better way to do things, and that, contrary to tradition, the crew’s insights might be more profound than even the captain’s. ... I asked everyone, “Is there a better way to do what you do?” Time after time, the answer was yes, and many of the answers were revelations to me. (emphasis added)

"My second assumption was that the secret to lasting change is to implement processes that people will enjoy carrying out. ... encouraging people not only to find better ways to do their jobs, but also to have fun as they did them. ... (emphasis added)

Without counsel, plans go awry, But in the multitude of counselors they are established.

Proverbs 15:22 (NKJV)



WW II, Korea, Viet Nam Veterans YouTube videos ( https://youtu.be/gVgU2LfumIc ) brings up loads of interviews on right side




B. High Reliability Organizations (HRO) principles


Making Effective Decisions and Fewer Error ( https://fs.blog/smart-decisions/ )


The decision-making principles in this Farnum Street article (above) are deliberate. They’re the result of many years of experience and experimentation. They draw upon the combined expertise of some of history’s deepest thinkers. They summarize the core insights and skills from several influential books on decision-making.

No One Taught You How to Decide ( https://fs.blog/smart-decisions/#how_to_decide )

Your Mind is a Pattern Matching Machine ( https://fs.blog/smart-decisions/#pattern_matching )

Decision Making ( https://fs.blog/smart-decisions/#decision_making )

Smart People Make Terrible Decisions ( https://fs.blog/smart-decisions/#smart_people_make_terrible_decisions )

Sources of Stupidity

Intelligent Preparation: The World Is Multidisciplinary ( https://fs.blog/smart-decisions/#intelligent_preparation )

How We Make Decisions ( https://fs.blog/smart-decisions/#how_we_decide )

General Thinking Concepts ( https://fs.blog/smart-decisions/#general_thinking_concepts )

Add To Your Decision Making Skills ( https://fs.blog/smart-decisions/#general_thinking_concepts )

Books to Improve Decisions ( https://fs.blog/smart-decisions/#books_to_improve_decisions )



There are plenty of good training and / or Refresher videos on wildland fire near-fatal and fatal events on YouTube and Vimeo. Expand your knowledge base - bearing in mind that all of these are based on faulty investigations avoiding the truth of what really happened and why. All of them with the alleged "investigators" that deliberately first established a conclusion, then found the "facts" to support it; often having the gall to call them "Factual."


Dramatists and novelists tend to condense and leave out elements that are irrelevant to the kind of stories they want to tell.

The way of fools seems right to them, but the wise listen to advice. Proverbs 12:15 (NIV)


The frog in the well knows nothing of the mighty ocean.” Japanese Proverb



Dr. Ted Putnam with MTDC and Dude Fire ( https://youtu.be/uJHqakI0Bc0 ) Ted Putnam with the Missoula Technology and Development Center (MTDC) describing fire shelter and personal protective equipment impacts on the June 26, 1990 Dude fire.


Battles Lost. (This is a NWCG video describing our fatality fire history, and our hard lessons learned. The narrator, Doug Copsey, is a professional actor and and narrator.

( https://youtu.be/y_GYZd-Dog4 ) Why are we failing to continue to learn lessons from the past?


Cramer Fire [Virtual] Staff Ride - Opening the Door -- May we learn from their ultimate sacrifice. The 2012 Cramer Fire Staff Ride. This video—a tribute to firefighters Shane Heath and Jeff Allen who lost their lives on the 2003 Cramer Fire—tells the story of the learning and healing that occurred on the 2012 Cramer Fire Staff Ride.

( https://youtu.be/ksMXpJXjj44 )


Cramer Fire Case Study - 2013 Refresher ( https://youtu.be/KBlU8eqH4hk ) A good portion at the beginning was Merl Saleen talking about the 1985 Butte Fire. Interesting!


Clay Springs Fire Burnover - 2012 - A burnover event from the 2012 Clay Springs Fire in Millard County, Utah. Firefighters from the Oak City Fire Department escaped tragedy through decisive thinking and quick action. Learn from their experience. ( https://youtu.be/qe7nl1tqclk )


Beaver Fire Entrapment FLA (2014) At approximately 1730 on August, 11, a Division Supervisor, contract dozer operator and a Heavy Equipment Boss deployed their fire shelters on the Beaver Fire on the Klamath National Forest in northern California (U.S. Forest Service Incident CA-KNF-005497). The individuals involved were improving line on the far western edge of the fire, approximately 2 miles from the fire front.

( https://www.youtube.com/watch?v=MYENvpiv1WA )


Cedar Fire Entrapment Briefing Video (2016) "This is the Cedar Fire Entrapment Briefing video which supports the Cedar Fire Factual Report." Excellent fire weather and fire behavior video clips

( https://www.youtube.com/watch?v=Yeprtvo2xsY )


Surviving a Rotating Plume - Lessons Learned from the Indians Fire Entrapment (2012) "During a wildfire burnout operation in extremely dry fuels, firefighters suddenly observe a massive rotating vertical plume. Unfortunately, the crews who watch it swirl across this ridgeline don't see the plume as an imminent threat to adjoining forces. These people will not underestimate the potential power of a rotating vertical plume ever again."

Another one with excellent fire weather and fire behavior video clips. I question the "firefighters suddenly observe a massive rotating vertical plume" assertion because the whole point of the video is that they watched and photographed and videoed the massive fire whirls for hours.

You get the drift. Literally scores worth of these videos.



Dude Fire - June 26: NWCG 6-Minutes For Safety


"This Day in History is a brief summary of a powerful learning opportunity and is not intended to second guess or be judgmental of decisions and actions. Put yourself in the following situation as if you do not know what the outcome will be. What are the conditions? What are you thinking? What are YOU doing?" ( https://www.nwcg.gov/committee/6mfs/dude-fire )


Well then, on the contrary, we fully intend to second guess or be judgmental of the fatal decisions and actions on the June 1990 Dude Fire.


Put yourself in the following situation as if you do not know what the outcome will be. What are the conditions? What are you thinking? What are YOU doing?



Oakland Hills Fire WUI


Because the Australians are often way ahead of us on fire weather and fire behavior research, consider now an Australian training video on very aggressive to extreme fire behavior in one of their unique fuel types (i.e. stringy bark). The principles of fluid dynamics (fire behavior) are basically the same. Except that these unique fuels characteristics allow for spotting distances of over five (5) miles. The fuel consistency allows the lofted firebrands to burn more like a like cigar and they curl in on themselves allowing them to float in the smoke columns for incredibly long distances without burning up.


Figure 13. testing equipment Source: CFA


Fire Behaviour: Observation & Training - CFA (Country Fire Authority)


"It is important for firefighters to have a good understanding of how vegetation burns under different conditions. This video shows two different types of fire behaviour in the same long unburnt stringy-bark forest. One fire was lit under mild weather, the other under typical bushfire conditions; resulting a stark contrast in fire behaviour."

( https://youtu.be/p1iZPR6aIBc )


Human behavior has been determined to play the largest role in wildland firefighter safety. In all fields of work, especially those (un)known essentially constant wildland fire risks, human behavior is the only factor that is responsible for either increasing or decreasing injury risks. Despite this fact and its key safety function, since the advent of Serious Accident Investigation Teams which then deteriorated to Learning Reviews ad nauseum, human behavior is more often disregarded as the antithesis of what we once called accident "investigations." Instead, they focus on bogus, irrelevant environmental and other irrelevant circumstances. Those are tertiary causal factors and far from the relevant human behaviors that led to the accident. This overemphasis on the irrelevant circumstances fails to consider the fact that the vast majority of accidents result from what is considered a normal work practice, not from known risky behavior.


According to "official" documents, the "Coordinated Response Protocol (CRP) and Learning Review (LR) are designed to make the process as painless as possible for all involved. ... The learning review consists of four phases designed to enhance sensemaking and to include technical, mechanical, and complex assessment of the incident being studied." ... (emphasis added)


( https://training.nwcg.gov/courses/UOHTML/Intro_Facilitated_Learning_Analysis/content/256.html )

( https://www.fs.usda.gov/rmrs/science-spotlights/coordinated-response-protocol-and-learning-review-serious-accidents )


( https://www.wildfirelessons.net/viewdocument/the-coordinated-response-protocol )


( http://wildfiretoday.com/wp-content/uploads/2014/08/WP-Coordinated-Response-Protocol-Paper.001.pdf )


Because all they tell are "stories" and fail to lay the necessary blame or find fault, we find it very difficult to rely on much in their reports because they completely fail to examine and / or address the human factors, errors, failures, etc. And telling the truth about what happened is often painful, an often indispensable step in the healing process. And so, because of all this, I consider it contrary to what they want us to accept and believe about it, and so we call it CRaP.


Dr. Herman's conclusions and advice (below) debunk and nullify much, if not most, of the CRaP method of discovering the truth about what truly happened and why. And certainly the necessary healing that follows.


"Because the truth is so difficult to face, survivors often vacillate in reconstructing their stories. Denial of reality makes them feel crazy, but acceptance of the full reality seems beyond what any human being can bear. Both patient and therapist must develop tolerance for some degree of uncertainty, even regarding the basic facts of the story. In the course of reconstruction, the story may change as missing pieces are recovered. This is particularly true in situations where the patient has had significant gaps in memory. Thus both patient and therapist must accept the fact that they do not have complete knowledge, and they must learn to live with ambiguity while exploring at a tolerable pace."


"Survivors understand that the natural human response to horrible events is to put them out of mind. They also understand that those who forget the past are often condemned to repeat it. It is for this reason that public truth‐telling is the common denominator of all social action." (footnote omitted)


"... be secure in the knowledge that simply in her willingness to tell the truth in public, she has taken the action that perpetrators fear the most."


"The survivor who undertakes public action also needs to come to terms with the fact that not every battle will be won. ... ongoing struggle to uphold the rule of law .... willingness to tell the truth in public ... the action that perpetrators fear the most. ..." (all emphasis added)


Herman, J.L., MD (2002) Recovery from psychological trauma. Psychiatry and Clinical Neurosciences (PCN), ( https://onlinelibrary.wiley.com/doi/full/10.1046/j.1440-1819.1998.0520s5S145.x )


Consider now this from the Trolley Experiment paper: "One important question is what the relationship is between a well-told story and one that is true, or ethically insightful."


Overall, based on what we read above regarding the respective FLA, CRaP, RLA, LR, ad nauseum "stories" of these tragedy survivors and what we are to believe from them in the words of the alleged "investigators" crafted into their final reports, we come to this conclusion. They are, at best, fallible ways of constructing what actually occurred and why rather imperfectly, as we then attempt to mentally and emotionally experience it, can distort as much as they illuminate. So should we give them the credence, validity, and weight as sources of truthful insight that "they" expect of us?

Let the wise listen and add to their learning, and let the discerning get guidance Proverbs 1:5 (NIV)


To address the relevant safety challenges, detailed consideration must be given to the common human behavior element. It is important that this training should include the rehearsal of behaviors as "realistic" as possible in order to prevail under stressful conditions, to overcome resorting to what we are normally most familiar with (e.g. South Canyon, Thirty Mile, and YH Fires). Safety critical behaviors must be practiced and over-practiced until they become automatic.


We must conclude that from the YH Fire SAIT-SAIR, and the ongoing attempts to maintain the "no blame, no fault" deception, the WF culture has learned "incomplete lessons."


"They showed that an organizational system failure, not individual failure, was behind both accidents, causing the negative pattern to repeat." This sounds almost identical to what occurred on the YH Fire with the GMHS, and is likely to occur elsewhere on other wildfires because of the "incomplete lessons" learned. (Challenger and Columbia Space Shuttle Disasters author Dianne Vaughan)


We must focus on the "complete" lessons learned in order to reduce the risks associated with wildland fire suppression to: (1) identify causal human behaviors that lead to the accidents; (2) determine the frequency of these behaviors; (3) evaluate and modify, if needed, the training programs and management systems that either (in)directly support the behaviors; and (4) develop a remedial training and management program to do things safely and efficiently.


Vaughan, D., (2005) System effects: on slippery slopes, repeating negative patterns, and learning from mistake? In: Starbuck, W.H., Farjoun, M. (Eds.), Organization at the Limit: Lessons from the Columbia Disaster. Blackwell Publishing, Malden, MA,


( http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.456.5317&rep=rep1&type=pdf )


Unfortunately, and yet realistically, there will always be fatalities - in every work group - due to human behaviors and human factors because personnel do some stupid, unsafe things at times. All we can do is reduce the attitudes and behaviors through "complete" lessons learned. Therein lies the problem.

High Reliability Organizations (HRO)


"In 1984, a group of University of California researchers studied operations and organizational culture in three organizations: the air traffic control system, a nuclear power plant, and U.S. Navy aircraft carriers. Their intent, broadly, was to determine why some organizations that routinely operate in high risk environments endure less than their fair share of accidents. The term “high reliability organization” (HRO) came from this research. Little hard data exists to quantify HROs, but researchers have broadly defined them, and they have described HRO qualities and characteristics. These descriptions may prove useful to organizations that are attempting to model practices and achieve results of high reliability organizations." (BLM HRO Workshop - 2010)


An organization that operates continuously under trying conditions and has fewer than its fair share of major incidents. (Karl E. Weick and Kathleen M. Sutcliffe)


An organization that has succeeded in avoiding catastrophes in an environment where normal accidents can be expected due to risk factors and complexity. (Wikipedia)

Figure 14. High Reliability Organization (HRO) Cultures and Principles Source: NIFC BLM


Karl Weick and Kathleen Sutcliffe cite wildland firefighting crews as one example of a high reliability organization in their book, Managing The Unexpected – Resilient Performance in an Age of Uncertainty. They ask their readers to use our organization as a benchmark, “not because they ‘have it right’ but because they struggle to get it right on a continuous basis.”


Strive to have employees operate in a hyper-vigilant state of mind. Hyper-vigilant employees “recognize even subtle signals, and know that the signal was significant in context.”


Quoting Karlene Roberts in New Challenges to Understanding Organizations, Hunter noted that employees in HROs: "1. Seek perfection but never expect to achieve it. 2. Demand complete safety but never expect it. 3. Dread surprise but always anticipate it. 4. Deliver reliability but never take it for granted. 5. Live by the book but are unwilling to die by it. "

The four key pillars for sustainable risk management taken from James Reason’s Managing the Risks of Organizational Accidents are:


Reporting Culture ~ Safety cultures are dependent on knowledge gained from near misses, mistakes, and other “free lessons.” People must feel willing to discuss their own errors in an open, non-punitive environment.


Just Culture ~ An atmosphere of trust where people are encouraged to provide essential safety-related information yet a clear line is drawn between acceptable and unacceptable behavior.


Flexible Culture ~ One that adapts to changing demands by flattening hierarchies and deferring to expertise regardless of rank.


Learning Culture ~ The combination of candid reporting, justice, and flexibility enables people to witness best practices and learn from ongoing hazard identification and new ways to cope with them.

This is the BLM stance on HROs - All other Agencies and Departments follow these same principles very closely.


There are a number of concepts, systems, methods, and models an organization can use in its “safety culture.” Many are useful, and most are complementary to one another. HRO theory is one of them. Toward this end, BLM fire personnel are encouraged to study HRO characteristics, or any other constructive safety practice, and apply them to their own units."


Tracking Small Failures.

HROs are preoccupied with all failures, especially small ones. Small things that go wrong are often early warning signals of deepening trouble and give insight into the health of the whole system.


A Reluctance to Simplify.


HROs restrain their temptation to simplify through diverse checks and balances, adversarial reviews, and the cultivation of multiple perspectives.


A Sensitivity to Operations.


HROs make strong responses to weak signals (indications that something might be amiss). Everyone values organizing to maintain situational awareness.


A Commitment to Resilience.


HROs pay close attention to their capability to improvise and act — without knowing in advance what will happen.


A Deference to Expertise.


HROs shift decisions away from formal authority toward expertise and experience. Decision making migrates to experts at all levels of the hierarchy.


HROs push decision making down to the front line (point of the spear), and authority migrates to the person with the most expertise, regardless of rank.


Expertise is not confused with experience. Experience by itself does not guarantee expertise. We must scan up and down the chain of command to find the right expertise needed to handle the current or potential problem.


Decision making should migrate to the person with the unique knowledge needed to confront the given situational complexities.


NICC NIFC NWCG HRO website ( https://www.nifc.gov/training/trainingHRO.html )


" ... a less mindful, less informed culture mismanages the unexpected, with fatal results." (emphasis added) Weick and Sutcliffe (2007) Managing the Unexpected. p. 111

Here is another HRO outfit well worth delving into with a lot of links and information sources and opportunities - "The Center for Catastrophic Risk Management (CCRM) is a group of academic researchers and practitioners who recognize the need for interdisciplinary solutions to avoid and mitigate tragic events. This group of internationally recognized experts in the fields of engineering, social science, medicine, public health, public policy, and law was formed following the mismanagement and tragic consequences of Hurricane Katrina to formulate ways for researchers and experts to share their lifesaving knowledge and experience with industry and government." (emphasis added) ( http://ccrm.berkeley.edu/index.shtml )


Figure 15. Center for Catastrophic Risk Management (CCRM) detail and links and more Source: CCRM, NICC

On to "Part 1c - Do our Wildland Fire (WF) Instructors foster "complete" lessons learned in the WF culture?" ...

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

Source: Yavapai County Records/SAIT Report/Documents.

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