Why Has the Wildland Fire LLC Lost Its Ethical Compass Defending The YH Fire SAIT-SAIR?
Authors Fred J. Schoeffler and other contributing authors
Restating the more worthy post title beyond the limited WIX title allowance: Why Has the Wildland Fire Lessons Learned Center Lost Its Ethical Compass Defending The Federal USFS-Funded June 30, 2013, SAIT-SAIR Conclusion of No Wrongdoing?
Figure 1. From the US Military Academy Cadet Prayer Source: Quotemaster
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Abbreviations used: Wildland Firefighters (WFs) - Firefighters (FFs).
For if the trumpet makes an uncertain sound, who will prepare for battle? So likewise you, unless you utter by the tongue words easy to understand, how will it be known what is spoken? For you will be speaking into the air. 1 Corinthians 14:8-9 (NKJV)
The Hellenistic philosopher Epictetus warned us many years ago to “Be selective about whom you take on as friends, colleagues, and neighbors. The world is full of agreeable and talented folk. The key is to keep company only with people who uplift you, whose presence calls forth your best. But remember that our moral influence is a two-way street, and we should thus make sure by our own thoughts, words, and deeds to be a positive influence on those we deal with. The real test of personal excellence lies in the attention we give to the often neglected small details of our conduct. Make it your business to draw out the best in others by being an exemplar yourself.” Epictetus (Greek Stoic philosopher; Teachings recorded in his Discourses and Enchiridion)
The West Point Academy Cadet Prayer briefly cited above is in its entirety at this juncture in order to complement the image in Figure 1:
"O God, our Father, Thou Searcher of Human hearts, help us to draw near to Thee in sincerity and truth. May our religion be filled with gladness and may our worship of Thee be natural.
"Strengthen and increase our admiration for honest dealing and clean thinking, and suffer not our hatred of hypocrisy and pretence ever to diminish. Encourage us in our endeavor to live above the common level of life. Make us to choose the harder right instead of the easier wrong, and never to be content with a half truth when the whole can be won.
"Endow us with courage that is born of loyalty to all that is noble and worthy, that scorns to compromise with vice and injustice and knows no fear when truth and right are in jeopardy.
"Guard us against flippancy and irreverance (sic) in the sacred things of life. Grant us new ties of friendship and new opportunities of service. Kindle our hearts in fellowship with those of a cheerful countenance, and soften our hearts with sympathy for those who sorrow and suffer.
"Help us to maintain the honor of the Corps untarnished and unsullied and to show forth in our lives the ideals of West Point in doing our duty to Thee and to our Country.
"All of which we ask in the name of the Great Friend and Master of all."
Source: West Point.org Inspirations (emphasis added)
Figure 2. Thomas Jefferson integrity quote Source: WLF LLC
The above Thomas Jefferson quote and the associated WLF LLC article titled: "You are the Example" (May 3, 2022) contain the following quotes by WLF LLC author Travis Dotson: "Who’s watching you? Somebody is. Whether you know it or not, someone is learning from how you behave. What do you want them to learn? ... Eventually you’re going to have to deal with the behavior you’ve modeled." (emphasis added)
Yes, indeed Mr. Dotson. Does that include all of you at the WLF LLC as well as the "Underground Honor the Fallen (HTF) Group"? And included in its couple dozen members were some of the highest-ranking firefighters from the various agencies in the wildland fire business: the Forest Service, Bureau of Land Management, and the Park Service. Their goal was to make sure [the] Yarnell Hill [Fire], the most publicized event in wildland firefighting history, forced some much-needed changes to the job’s outdated culture. Three years later, they tried to spark “an age of enlightenment” in wildland fire.
And while you are revealing and/or failing to reveal the truth about the YH Fire and GMHS debacle, the entire world - especially WFs and FFs - are watching and reading, analyzing, and accepting as if it was credible what the WLF LLC posits and posts! However, if it deals with anything at all about the June 30, 2013, Yarnell Hill Fire and GMHS debacle, then caution, utmost due diligence, and extreme discernment are in order and necessary for what is required to seek the truth; because this author alleges that the WLF LLC would much rather discuss and publicize the "official" and alleged "Factual" truth as it is duly published in the Federally-funded SAIT-SAIR in order to curry favor with them or as directed by them.
This post will be a logical extension of our April 28, 2022, YHFR post titled:
What Are the Underground Honor the Fallen Group Ulterior Motives For Defending the GMHS Decisions? Our goal is to tie in the Wildland Fire Lessons Learned Center (WLF LLC) with the Honor the Fallen (HTF) Group and attempt to show their alleged concerted, controlling connection and their Federally-funded leadership in the cover-up, lie, and whitewash of the June 30, 2013, YH Fire and GMHS debacle. And this includes an all-out, albeit subtle at times, effort to discredit the established Fire Orders and Watch Out Situations and other Rules of Engagement; all in order to justify the Federally-funded SAIT-SAIR predetermined conclusion of no blame, no-fault, and no wrongdoing.
So then, why would the WLF LLC instead prefer to justify mistaken beliefs, behavior, numerous mistakes, misjudgments, or misfortune and practices about the YH Fire and GMHS debacle rather than positively change them for more truthful reliable ones for the benefit of the many WFs, FFs, and interested and discerning public?
To answer that, this is a suitable relevant quote from a subchapter on the 1996 Mt. Everest mountaineering disaster that applies quite well to the YH Fire and GMHS debacle and how the WLF LLC is accomplishing this with fullfledged intent. "In the absence of post-event processing and reflection, organizations likely fail to capture lessons learned in order to build the capacity of individuals and teams to meet future challenges." (emphasis added) Citing from the book titled: "Extreme Leadership - Leaders, Teams, and Situations Outside the Norm" (Editors C. M. Giannantonio and A. E. Hurley-Hanson) in the subchapter "Leadership at the edge of the summit" (B. S. Coffey and S. E. Anderson) p. 81.
In other words, there is nothing in that "likely fail" phrase about it. This author and others allege that the WLF LLC successfully ensured there are "incomplete lessons to be learned" that must square with the YH Fire SAIT-SAIR no-blame, no-fault conclusion in order to complete their ruse.
In the absence of post-event processing and reflection, organizations likely fail to capture lessons learned in order to build the capacity of individuals and teams to meet future challenges.
Extreme Leadership: Leaders, Teams and Situations Outside the Norm (2013)
In all fairness, the authors and many others believe that the WLF LLC has, with some exceptions supporting the various alleged means of reviews or faux "investigations," done an excellent job of providing mostly valuable information to reduce WF and FF tragedies.
However, there has been a very noticeable, and ever-increasing shift away from their mandated stance ever since the June 30, 2013, Federally-funded YH Fire SAIT-SAIR and GMHS debacle. One of their justifying "reasons" is likely to validate the untenable SAIT-SAIR conclusion: "The judgments and decisions of the incident management organizations managing this fire were reasonable. Firefighters performed within their scope of duty, as defined by their respective organizations. And found no indication of negligence, reckless actions, or violations of policy or protocol." (p. 4) (emphasis added) It is generally accepted as fact in the WF, FF, and non-HTF communities that this would have been an impossible feat.
Based on that conclusion reframed in the positive, our prior February 13, 2022, YHFR post is worth visiting: How was it possible to do everything right and yet 19 PFD FFs died in one fell swoop on June 30, 2013?
Consider now some excerpts from a research paper titled "The Dark Side of Organizations" by Challenger (1986) and Columbia (2003) space shuttle disasters author: she "examine[s] three types of routine nonconformity with adverse outcomes that harm the public: mistake, misconduct, and disaster produced in and by organizations. Searching for analogies and differences, I find that in common, routine nonconformity, mistake, misconduct, and disaster are systematically produced by the interconnection between environment, organizations, cognition, and choice." (emphasis added)
You may recall from our April 28, 2022, YHFR post titled: What Are the Underground Honor the Fallen Group Ulterior Motives For Defending the GMHS Decisions?: "... the general consensus of the SW Area HS Crews during their October 2013 Fall After Action (AAR) Review at the Prescott NF Fire Center, Helms BSR, GMHS lunch spot, and fatality sites that had worked with Marsh ... revealed during a YH Fire and GMHS Deployment Site Visit Integration Phase statement from a senior USFS NM HS Supt., i.e 'This was the final fatal link in a long chain of bad decisions with good outcomes, we saw this coming for years' - with about a dozen others stating they had attempted peer pressure with the GMHS to change their ways for years and were unsuccessful." (emphasis in original)
Vaughan defines the Normalization of Deviance phrase in The Dark Side of Organizations: Mistake, Misconduct, and Disaster (1999) as: "An event, activity, or circumstance occurring in and/or produced by a formal organization that deviates from both formal design goals and normative standards or expectations, either in the fact of its occurrence or in its consequences and produces a suboptimal outcome as organizational deviance." (italicized emphasis in original)
In the 1986 Challenger Launch Decision, "Vaughan explains how an organization like NASA socially embraced errors, oversights, and flaws, considering such items normal over time; and how such complex social systems can influence and alter groups, and summarizes the normalization of deviance within NASA during the shuttle program. Related to the Challenger catastrophe, Vaughan explored how the recognition of industrial deviation was discovered and interpreted in a way that was 'normalized' at NASA, and 'then finally officially labeled an acceptable risk.'”
Figure 2a. Snippet of organizational deviance from the Dark Side of Organizations Source: Vaughan
According to "Mistakes Were Made But Not By Me" by authors Tavris and Aaronson: "The engine that drives self-justification, the energy that produces the need to justify our actions and decisions - especially the wrong ones - is the unpleasant feeling that Festinger called 'cognitive dissonance.' Cognitive dissonance is a state of tension that occurs when a person holds two cognitions (ideas, attitudes, beliefs, opinions) that are psychologically inconsistent with each other. ... Dissonance is disquieting because to hold two ideas that contradict each other is to flirt with absurdity." (emphasis added) pp. 17-18. See also a 2017 Skeptical Inquirer article by the same authors as well on the subject titled: "Why We Believe —Long After We Shouldn’t."
And one should always consider George Orwell's 1984 as he ventures quite a bit further with his credible notion of Doublethink - grasping onto two opposing thoughts as being true at the same time. (Changing Minds) This author feels that this is actually so prevalent in many areas of the wildland fire realm that many will unknowingly, unquestionably, and thus willingly accept these alleged "factual" investigations and other "review approaches" based on their predetermined conclusions bolstered with convenient alleged "facts" to support them. And they do it because the ostensibly trustworthy WLF LLC promotes them, fostering Kool-Aid Drinkers.
The authors and many more actively concerned, informed, and interested others allege that anything and everything to do with the YH Fire and the GMHS debacle is skewed in favor of supporting the false predetermined no-blame and no-fault conclusion paid for by the USFS as attested to by one of the SAIT "Investigators" (i.e. 'what do you think about Tom Harbor and the USFS paying for the SAIT investigation?') and one of the ADOSH Investigators stated that 'it was obvious that the USFS was controlling the investigation.'
The crowning hypocrisy of this is that the so-called "Underground" Honor the Fallen Group - through the venue of the Federally-funded WLF LLC - is actively engaged in discrediting the Rules of Engagement that have stood the test of time until the June 2013 YH Fire. In the blink of an eye, that trend was reversed while blatantly ignoring them in their listening and responding only "Reading, Reflecting, and Changing Behavior" PodCast. It was a real struggle to listen to because there is no way to stop and go back or any of those functions as on YouTube or Vimeo.
And remind me - why is there a need for the WLF LLC to be "Changing Behavior" when the Rules of Engagement were - and will continue to be - working just fine? Along those same lines, a Safety Matters member, a retired smokejumper and National Park Service manager similarly noted: “For better or worse, NWCG [National Wildfire Coordinating Group] has taken the position that the 10 Standard Fire Orders are now to be considered guidelines and not absolute orders. ... No explanation ... why rules that have been in place for 50 years are suddenly guidelines” (emphasis added) (Thuermer, 2014) This is a most telling statement.
“Nearly all men can stand adversity, but if you want to test a man’s character, give him power.”
According to authors Tavris and Aronson in "Mistake Were Made But Not By Me (2020): "We need a few trusted naysayers in our lives, critics who are willing to puncture our protective bubble of self-justifications and yank us back to reality if we veer too far off. This is especially important for people in positions of power. ... Abraham Lincoln was one of the rare presidents who understood the importance of surrounding himself with people willing to disagree with him." (emphasis added) p. 91
Unless it is the WLF LLC totally on its own, it's fair to say that the WLF LLC and those who hold "positions of power" over them have directed them to continue with the cover-ups, lies, and whitewash of the YH Fire and GMHS debacle. You may recall from a December 11, 2019, YHFR post: "Instructors at National USFS Wildland Fire Apprenticeship Academies, various quasi-private / municipal Wildfire Training Academies, and local USFS Ranger Districts were required to cite and utilize, and therefore, follow only the SAIT-SAIR "conclusions" and what is presented in the associated YH Fire SAIT PowerPoint and "briefing video." And USFS Apprenticeship Instructors were required to provide lesson plans for "Regional Office and Washington Office approval" if they were to discuss anything at all about the Yarnell Hill Fire while instructing at the USFS National Apprenticeship Academy in CA. (only italicized emphasis added)
Figure 3. Snippets of WLF LLC Mission Statement (left) WLF LLC HRO Mission Statement (right) Source: WLF LLC, National Wildfire Coordinating Group (NWCG)
The Fall 2007 WLF LLC Mission Statement that follows differs from the one in Figure 3. above: "Wildland Fire Lessons Learned Center actively promotes a learning culture to enhance and sustain safe and effective work practices in the wildland fire community. The Center provides opportunities and resources to foster collaboration among all fire professionals, facilitates their networks, provides access to state-of-the-art learning tools, and links learning to training." (emphasis added)
The name of their WLF LLC website including the words "Lessons Learned" refers to the idea that if lessons are shared and learned from, they can change behaviors that enhance wildland firefighter safety. That is all well and good, however, this author alleges that they are disguising and outright hiding most of those lessons. And for the most part, the lessons that we do "learn" are "incomplete" and therefore of little value.
Moreover, the utilitarian word "collaboration" they use has some interesting definitions. The one we're all most familiar with is pretty benign: "the action of working with someone to produce or create something." However, the more sinister one is defined as: "traitorous cooperation with an enemy" and synonyms such as: "fraternizing, collusion, consorting, conspiring", etc. The authors and others allege that the latter definition is likely more accurate for what has been occurring after the YH Fire and GMHS debacle and the SAIT-SAIR "conclusion." This includes the discrediting of the solid Entrapment Avoidance protocols and Rules of Engagement, i.e. the "10 & 18."
In the book "Mistakes Were Made But Not By Me" author Tavris states: "There are plenty of good reasons for admitting mistakes, starting with the simple likelihood that you will probably be found out anyway." (emphasis added) The WLF LLC has failed to admit any "mistakes" regarding the YH Fire and GMHS debacle. And yes indeed, they have been "found out."
Tavris and Aronson write this about organizations such as the WLF LLC and their public responsibilities: "[A]t least public-interest groups, watchdog agencies, and independent scientists can eventually blow the whistle on bad or deceptive research." (emphasis added) However, the second half of their statement is more telling and aligned with what the WLF LLC is more likely doing. Paraphrasing, the greater danger to the public comes from the self-justifications of well-intentioned individuals, who because of their need to reduce dissonance, truly believe themselves to be above the influence of those that fund them. (emphasis added) (p. 66) Based on the Federally-funded WLF LLC stance on the June 30, 2013, YH Fire and GMHS debacle for the past several years, it's safe to say that this is a fairly accurate statement by Tavris and Aronson.
You will readily note that the WLF LLC Mission Statement has included nothing whatsoever about accuracy or the truth. In their Disclaimer below they state: "No warranty or guarantee is implied because much of the data provided is beyond the control of the center." (emphasis added) That latter highlighted statement may have been true in 2002 when they started, but after the June 30, 2013, YH Fire and GMHS debacle it is highly questionable; and actually much more disingenuous. Consider now several quotes and excerpts detailing the genesis of the Wildland Lessons Learned Center (WLF LLC) and its participants.
Here is a Federal Outreach for a "Fire Management Specialist (Wildland Fire Lessons Learned Center (LLC) Manager) Department of the Interior (2020) by the American Geosciences Institute for the WLF LLC Center Manager position revealing some telling requirements. The primary one in this author's professional opinion is directly related to integrity involving one of the primary components of the WLF LLC regarding the production of "accurate knowledge products containing lessons learned and effective practices" for this managerial position. (emphasis added)
"The primary purpose of this position is to provide senior level professional wildland fire management expertise to, and management of, the Wildland Fire Lessons Learned Center (LLC) program functions. This entails providing strategic and operational direction, fire management advice, and leadership for the LLC as well as developing, requesting, and managing the LLC budget. All activities are conducted in an interagency environment. The incumbent provides direction and maintains effective processes for gathering, verifying, and analyzing observations and information from a variety of sources to produce accurate knowledge products containing lessons learned and effective practices. The LLC Manager provides technical oversight to interagency employees and the full range of supervisory responsibilities to other NPS staff at the LLC. The incumbent oversees the management of contracts in cooperation with federal land management agency contracting officers. The LLC Center Manager participates in workshops, seminars, conferences, fire meetings, and other venues to transfer applicable lessons and effective practices. The incumbent may participate in wildland fire and all hazard response activities based on qualifications and availability." (emphasis added)
So then, how is it that the WLF LLC Reading, Reflecting, and Changing Behavior" PodCast professionals responsible for "gathering, verifying, and analyzing observations and information from a variety of sources to produce accurate knowledge products containing lessons learned and effective practices" fails to mention anything at all about the June 30, 2013, YH Fire and GMHS debacle? Because there is an alleged clear intent to deceive. They did, in fact, cover both the "gathering" and "analyzing" portions, however, they completely missed the boat on the most important one - "verifying" - the truth and acknowledging the YH Fire and GMHS debacle which is completely absent from the WLF LLC PodCast.
The incumbent provides direction and maintains effective processes for gathering, verifying, and analyzing observations and information from a variety of sources to produce accurate knowledge products containing lessons learned and effective practices.
This author had a direct involvement in the creation and inception of the WLF LLC in 2002 when he hand-delivered about 60-80 hard copy wildland fire investigation reports of burnovers, entrapments, shelter deployments, and fatalities to then-Center Manager Paula Nasiatka. There has never been any public acknowledgment of this fact by the WLF LLC. Former Center Manager Brit Rosso would acknowledge me privately one-on-one at a conference or meeting but never publicly nor anywhere on their WLF LLC website. Do you think it had anything to do with being Politically Incorrect or a Truth Teller ... or both?
Figure 3a. Snippet of original WLF LLC Center Manager Paula Nasiatka extolling the virtues of HRO at the 2007 Wildland Fire Workshop Source: NWCG, WLF LLC
"How We Got Here" "The year 2012 marked the Wildland Fire Lessons Learned Center’s (LCC) tenth year of operation. This milestone became an opportunity to remember and reflect on how our LLC journey began. We should never forget the 1994 South Canyon Fire that killed 14 wildland firefighters. This tragedy triggered the interagency TriData Firefighter Safety Awareness Study that recommended a permanent “lessons learned” program be established for wildland firefighters: Wildland Fire Safety Awareness Study Phase III, Appendix A." (emphasis added)
Created as a result of the 1994 South Canyon Fire tragedy, "the LLC’s primary goal continues to be striving to improve safe work performance and organizational learning for all wildland firefighters." (emphasis added) They have the "lessons learned program" part down, however, they are seriously lacking in the "organizational learning" portion as they relate to the accuracy and truth about the YH Fire and GMHS debacle.
Figure 4. Snippet of South Canyon Fire photograph of Investigative Report Figure 10. revealing WFs and possibly SJs working in the thick Gambel Oak. Source: USFS RMRS-RP-9, Sept. 1998
Figure 4a. Snippet of South Canyon Fire photograph revealing Smokejumper looking downslope at dense brush and intense fire behavior running upslope. In their goal of sensitivity, the cloudy, milky white areas are airbrushed-out WFs attempting to escape the approaching fire. Source: WLF LLC - The View From Here
USDA USFS Rocky Mountain Research Station RMRS-RP-9, Sept 1998 Fire Behavior Associated with the 1994 South Canyon Fire on Storm King
Mountain, Colorado by Bret W. Butler, Roberta A. Bartlette, Larry S. Bradshaw, Jack D. Cohen, Patricia L. Andrews, Ted Putnam, Richard J. Mangan
"Consequently, in 2002 the Wildland Fire Lessons Learned Center was created. Today , the LLC operates as a national, interagency, federally-funded organization with interagency staffing. The LLC’s primary goal continues to be striving to improve safe work performance and organizational learning for all wildland firefighters." (emphasis added)
This is all well and good, however, we need to ask ourselves - are they really continuing to "improve safe work performance and organizational learning for all wildland firefighters" when they fail to tell the truth, the whole truth, and nothing but the truth about the YH Fire and GMHS debacle?
High-Reliability Organization (HRO) Discussion
Figure 5. Snippet of Five HRO Principles Source: NWCG, WLF LLC
Figures 5a., 5b., 5c. Snippets of NWCG sponsored Wildland Fire Workshop HRO Introduction Conference (2008) cover promoting the concept (left); WLF LLC shield promoting HRO (upper right); WLF LLC Fall 2007 HRO and Organizational Learning stance (lower right) Source: NWCG, WLF LLC
In the NWCG-sponsored Wildland Fire Workshop HRO Introduction Conference (2008) publication (58 pp.), the term "HRO" is cited 145 times.
The following was an interesting find while searching specifically for the WLF LLC and High Reliability Organizations (HRO) on the internet based on the WLF LLC statements made above. And what turned up was that the Wildland Fire Lessons Learned Center (LLC) in a 2010-2012 proposal sought out a "Next Generation Knowledge Management System (2010 – 2012) Challenge" from the "Working Knowledge CSP"- a very small, very obscure consulting group. (emphasis added). They are located in the heartland region of the United States - Washington, DC.
From "dun & bradstreet" website Company Profile
Doing Business As: Working Knowledge Csp, LLC
Company Description: Working Knowledge Csp, LLC is located in Camas, WA, United States and is part of the Management, Scientific, and Technical Consulting Services Industry.
Working Knowledge Csp, LLC has 1 [one] total employee across all of its locations and generates $114,780 in sales (USD). (Sales figure is modeled).
Key Principal: William S Kaplan
"The 'op tempo' for fighting fires required an ability to easily and rapidly transfer knowledge within teams and across teams.
"The fire management leadership and its workforce were dealing with an increasing risk of personnel turnover as the workforce ages presenting an unacceptable risk of critical knowledge loss that will severely impact successful fire management outcomes.
"Improvement in a consistent and disciplined process for 'capturing, adapting, transferring, and reusing' critical fire management knowledge that is part of the fire management processes and practices essential for protecting natural and personal resources, the lives of those being protected, and those providing the protection.
"Recognized need for an evolutionary change in the management of critical and relevant knowledge while maintaining the focus necessary to operate as a High-Reliability Organization (HRO).
"Challenges in making change happen and the desire to evolve into a benchmark learning organization where people share what others need to know to improve overall individual and fire management team operating performance while reducing risk of harm and loss.
Solution "As part of an 8a Joint Venture delivery team, the Working Knowledge CSP solution deployed “fit for purpose” KM technology, providing the fire community with an improved ability to learn and adapt quickly, improve collaboration within and across fire teams, and continue to build bridges across the vast number of agencies and organizations that form the greater fire management community. This provided for continuous feedbak (sic) loops of engagement and knowledge flow."
"There were several interrelated projects that comprised the effort:
"Technology project component was accomplished in three phases:
"Improve the quality and visibility of the content
"Optimize the search capability
"Enable a leading-edge user interface and functionality.
"Learning project component:
"Learning processes already in place were evaluated and evolved by engaging the end users of this knowledge
"Critical and highly relevant knowledge was identified and captured or created
"Sustainment of the Working KnowledgeCSP Operationalizing Learning© Concept.
"Collaboration project component:
"Communities of Practice were enhanced and sustained including outreach to the greater fire community." (all emphasis added above)
So then, why is it that the WLF LLC professionally sought out guidance that revealed the utilization of the High-Reliability Organization (HRO) principles? However, based on negative GTS (Google That S**t) search results, this never appears to have been truly adopted and promulgated by the WLF LLC in spite of the highly efficient and effective style of HRO-like "organizational learning" that they suggested exists. Why is that?
Consider now some recent (May 12, 2022) Snippets of GTS searches for the WLF LLC and HROs. The only one that shows up is this obscure consulting firm but never the WLF LLC itself.
Figure 6. HRO Google search results without the WLF LLC being mentioned Source: Google
"A lesson is learned when we change our behavior"
This author holds that endorsing, maintaining, and promoting the tried-and-true "10 and 18" Fire Orders and Watch Out Situations as designed and utilized safely and successfully for years would be a great start. This includes all those other WFs and FFs on the June 2013 YH Fire. That would certainly improve WF and FF safety. However, since the established pattern anymore is the odious Facilitated Learning Analysis (FLA), Coordinated Response Protocol (CRaP), or Learning Reviews (LR), it militates toward "incomplete lessons learned" per author and researcher Diane Vaughan coined that term to describe the Challenger (1986) and Columbia (2003) NASA shuttle disasters debacles.
In the link provided, please consider this valuable human factors collection (409 pp.) by Farjoun and Starbuck (2005) titled "Organization at the Limits" where Vaughan also wrote quite a lot on the notions of "incomplete learning processes" and "incomplete lessons learned."
Consider now the National Advance Fire & Resource Institute (NAFRI) (and by default the WLF LLC as well) FLA Introduction and Welcome:
"The Facilitated Learning Analysis (FLA) is a process progressive leaders can utilize to treat accidents and other unintended outcomes as opportunities to learn and better understand how employees perceive and manage risk. This view may also offer a safe opportunity for those involved to share their story. The FLA process demonstrates to employees, through their own words, what they can learn from unintended outcomes and how they may reduce the possibility of them happening again." (emphasis added)
WLF LLC FLA video. "This video introduces the Facilitated Learning Analysis (FLA) history, key concepts and processes which are used to review many accidents and incidents. The video is intended to relieve the concerns and fears of employees and supervisors who need to participate in an FLA as well as to educate all firefighters on how FLAs are used for sharing lessons learned. The video was produced by the USFS National Technology and Development Program – Missoula."
Figure 7. Snippet of Closed Caption text of Randy Draeger. Former Marine with Hotel Management skills promoted to Region 4 USFS Regional Safety and Health Manager. Source: WLF LLC, MTDC, YouTube, FLA
Figure 8. Snippet of Closed Caption text of Randy Draeger, skills promoted to Region 4 USFS Regional Safety and Health Manager. Source: WLF LLC, YouTube, FLA
Figure 9. Snippet of Closed Caption text of Steve Holdsembeck,"promoted" from District Ranger to Region 4 USFS Regional Safety and Health Manager, then FLA Coordinator. Source: WLF LLC, YouTube, FLA
This author alleges that both Draeger and Holdsembeck have been part and parcel of failing to reveal the truth about many wildland fire disasters and mishaps along with the YH Fire and GMHS debacle.
Figure 10. Snippet of Closed Caption text of Assistant Director-Doctrine, Learning, & Risk Management Julian Affuso at U.S. Forest Service, Washington Office. Source: WLF LLC, YouTube, FLA
This author and many others contend that both Draeger and Holsembeck are alleged to be a big part of the cover-up, lie, and whitewash of the YH Fire and GMHS debacle based on personal conversations and emails.
Consider now this New Times article with Dr. Ted Putnam and former HS Mark Kaib supporting the above statement about the YH Fire and GMHS debacle. Wildfire Expert Alleges Arizona Forestry Division Covering Up Yarnell Hill Tragedy 05 April 2016 published by www.phoenixnewtimes.com
Consider now an April 4, 2016, InvestigativeMEDIA thread posted by WantsToKnowTheTruth (WTKTT) from Shari Turbyfill, Mother of Travis Turbyfill, one of the GMHS Marines, regarding the YH Fire and GMHS debacle cover-up, lies, and whitewash after participating in the April 2016 GMHS Family Staff Ride (all emphasis is added):
"The parents of David and Shari Turbyfill and others both on the Family Staff Ride and commenters also posted PUBLIC comments to their own ‘Yarnell Fire Realities’ Public Group page on Facebook the day AFTER this ‘YH Fire Staff Ride’ ( which they participated in )… and they were pretty much DISGUSTED with everything they heard… and ESPECIALLY with Bravo 33’s John Burfiend’s comments and ‘condescending attitude’ in particular.
Facebook GROUP – Yarnell Fire Realities Moderator(s): David and Shari Turbyfill ( parents of deceased GM Hotshot Travis Turbyfill ) https://www.facebook.com/YarnellFireRealities/
Shari Turbyfill talking about the April 5, 2016 ‘Yarnell Hill Fire Family Staff Ride’… and about HER face-to-face ‘conversation’ with Bravo 33’s John Burfiend…
——————————————————————————– Bret Henry – April 14 at 6:11 pm I believe, sadly, and from 23 years of fire experience, and after 9 years in the Marines, that, not always, but many fire management people, especially at the municipal level are, like politicians, sociopathic ego maniacs. Ie; listen to radio traffic on some tragedies… telling crews to be quiet that were calling for help. Many have heard this traffic… I wonder how that guy feels now, is he sad and it’s hard to live with or is he a chief somewhere enjoying many benefits and getting his lunch money back that was taken form (sic) him, telling grand stories of fire to any that listen.
Yarnell Fire Realities – April 14 at 6:06 pm Brett Henry I asked him ( John Burfiend ) that question face to face of The Man Behind the microphone of Bravo 33. They fall back on some training saying proper protocol for emergency break in which we’ve discovered throughout the nation is not standard its random. There is no rule or guideline in wildfire….strutual (sic) yes……so more cover up more excuses no more truth ... truth is in the ground. this is JFK and Jimmy Hoffa all over again….. Arizona State Fire will never be a stand-up Department of the state with the personnel and culture currently in place. They have the truth but they’d rather cover their asses than be stand up people and do the right thing. We will never know the truth and that is really personal for 19 families – Shari ( Turbyfill )
Bret Henry – April 14 at 6:09 pm Very sad. Generally speaking, it’s a bad culture. I would almost like to hear that he ( John Burfiend ) felt bad at least, for that.
Yarnell Fire Realities – April 14 at 8:12 pm He ( John Burfiend ) did… and THEN proceeded to ‘educate me’ on why it wasn’t HIS fault. ——————————————————————————–
And here are more comments from Shari Turbyfill posted just 24 hours after she and her husband David participated in this ‘YH Fire Family Staff Ride’…
——————————————————————————– Yarnell Fire Realities – April 6 at 12:59 pm Some of us spent yesterday ( April 5, 2016 ) with all of the leaders of that fire and after a grueling 6 hour hike and stations of conversation at certain points it is my belief as far as Arizona State Fire goes it is very disconnected and there appears to be more of a culture of Delegation and not my job then true honesty integrity and transparency I’m a very unpopular person for having this opinion but my opinion was formed by the events that took place yesterday that I witnessed for myself. How do you change a culture when the leaders see nothing wrong with it? When asked questions and the answers are I don’t know. And how sad it is to read the comment of David Sheets to never trust overhead. But with my experience sadly to say I think he’s right Wildland firefighting needs to be revamped completely the fires are different the world is different we can’t rely on how it used to be….. it’s killing us. I find this page valuable to those who want the truth. I also want those who read this page to know that the truth is very difficult to find. Rumors and gossip flow much more freely because you don’t have to prove it. This comment is posted exclusively from the observation and opinions I saw and formed yesterday – Shari ( Turbyfill )
Chad Walker – April 12 at 9:11 pm Phoenix New Times Wildfire Expert Alleges Arizona Forestry Division Covering Up Yarnell Hill Tragedy Published: Tuesday, April 5, 2016 – By John Dougherty http://www.phoenixnewtimes.com/…/wildfire-expert… Have you seen any of these videos or pictures that the article speaks about?
Yarnell Fire Realities – April 13 at 12:31 pm Yes Chad we have and hiked and saw with our own eyes the supposed decent (sic) to the ranch safety zone….you can not see the bowl where they died until you are half way down a rugged descent and it’s to the left on your right is a wall of boulders those boys had to be ordered down to Yarnell to reengage I cannot imagine them voluntarily choosing that path and then when the fire roared over the ranch they had no opportunity but to maybe go left and create a deployment site because there were no Communications. When it went bad it all went bad quickly and Bravo 33 was not much help by ignoring the repeated requests from Granite Mountain 7 [There is no Granite Mountain 7]. Our boys are gone and covered in a veil of unclear cover-your-ass poor management. There are so many holes and so many disconnected answers from Arizona State Fire that I wouldn’t trust their policies guidelines and procedures to put out a piece of paper on fire in my kitchen sink. If you’re a wildland firefighter in the state of Arizona … Know for sure that the boys in Phoenix sitting at their desks being important don’t have your back they’re too busy covering their own ass. Instead of spending two and a half years blowing smoke up our ass trying to tell the families that our boys were idiots…. wouldn’t it have been more effective for Arizona State leadership to just tell the truth take the hit and be better for all the future Wildland firefighters in our state…… Nope cya is The Game Plan and more people will die it hurts my heart – Shari ( Turbyfill )
Suzanne Flynn – April 20 at 10:53 pm Yarnell Fire Realities I’m very sorry for your loss.. I have been watching since the moment we all found out. You are not alone in your conclusion. with 27 years in this business and the past 13 mainly teaching, I have had a very difficult time with this particular accident. Please continue to search for your answers.
Diane Lomas – May 17 at 11:28 am Interesting developments on Investigative Media chapter XXI on May 16 and 17th.
Pat Byrnes – May 22 at 10:23 am Actually, the tragedy was on a Sunday afternoon, so the fire management folks in Phoenix were probably out on the golf course or having a pool party…. Sigh. Know that the 19 are remembered and many people would like to know and learn.
Yarnell Fire Realities – May 22 at 10:35 am We will keep trying… And to Diane Lomas… investigativemedia cannot be judged on its individual articles this is a long process and I think if you stick with reading all of the chapters there are more to come many more. Read just the words without forming opinions … we can get more truth. I know John [Dougherty] has pissed off a lot of people in his style of Journalism. Journalism in and of itself is part drama to gain your your readership and and part reality for facts. I would say stay open-minded read the words and wait for the ending." (emphasis added)
Recall the April 12, 2016, email thread between USFS Shelton LaVelle, Human Dimensions Joseph R. Harris, and BRHS HS Supt. Frisby regarding the proposed GMHS Staff Ride and "Human Factors!" Frisby noted that "The picture that is being painted is very different than what we remember ... and "that human factors that day were off the charts" and "swept under the rug." (emphasis added)
Figure 10a. April 12, 2016, email thread between USFS Shelton LaVelle, Human Dimensions Joseph R. Harris, and BRHS HS Supt. Frisby regarding the proposed GMHS Staff Ride and "Human Factors!" Source: YHFR