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Why Were Vital Human Factors Influencing the June 30, 2013, YH Fire GMHS Fatalities Never Revealed?


Author and Contributing authors: Fred J. Schoeffler and Lance Honda (RiP) and Joy A. Collura


Part 1 of 2 - Why Were Vital Human Factors Influencing the June 30, 2013, YH Fire GMHS Fatalities Never Revealed?


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. Thank you.


Abbreviations used below: Wildland Firefighters (WFs) - Firefighters (FFs).



Figure 1. AZ State Forestry Photo IMG 1334 - Intense fire behavior from one of several likely firing operations influenced by alignment of heavy chaparral fuels, chimneys and chutes, pushed by intense thunderstorm outflow winds on Sunday June 30, 2013, around 4:29 PM (1629). Google Earth overlay depicts GMHS Mackenzie photo point, mid-slope road, GMHS descent point and descent path, GMHS Deployment Zone, and Boulder Springs Ranch (out of sight behind the foreground ridge). Source: ASF Brian Lauber; WTKTT


This photo was taken by ASF Brian Lauber from Hwy 89 near the Assembly of God Church in Yarnell, AZ. This photo is used most often by the authors because it best reflects one of the main themes of this YHFR website - the extreme fire behavior result of likely one of several firing operations and the fatal GMHS decision to leave their Safety Zone ("the black"). This occurred when they made this decision without clearly and specifically notifying anyone (supervisor or Air Attack) of their intentions.

For our struggle is not against flesh and blood, but against the rulers, against the authorities, against the powers of this dark world and against the spiritual forces of evil in the heavenly realms. Ephesians 6:12 (NIV)


 

Consider now some quotes about work, knowledge, trust, and planning.

Louis "Studs" Terkel, American author, historian, actor, and broadcaster writes: "Work is about daily meaning as well as daily bread; for recognition as well as cash; in short, for a sort of life rather than a Monday-through-Friday sort of dying....We have a right to ask of work that it include meaning, recognition, astonishment and life." (Student of Fire Facebook)


"Knowledge brokering isn't just about more experienced people passing on information to the new guys. It's about understanding who has the skills and knowledge in each area and how those people can become teachers and facilitators instead of merely subject-matter experts." Trustology - The Art and Science of Leading High-Trust Teams - Richard Fagerlin


"Trust isn’t what we 'do'—it’s what results from what we do. Trust is the single most important factor in determining whether a group of individuals will become a high-functioning, high-performance team. With all of that at stake, it’s time to be intentional about trust."


"Trust has never existed in a risk-free environment. No matter how well you know someone, given enough opportunities, every one will fall short in some way or another. High-trust teams are strong, but it's a strength that comes through mutual vulnerability. If you are not willing to accept the fundamental vulnerability of high trust teams, you'll never have one." Trustology - The Art and Science of Leading High-Trust Teams - Richard Fagerlin


"Through careful contingency planning, a leader can anticipate likely challenges that could arise during execution and map out an effective response to those challenges before they happen. That leader and his or her team are far more likely to win." Extreme Ownership by former Navy SEALS Jocko Willink and Leif Babin

 

This Yarnell Hill Fire Revelations ( YHFR ) post is titled to a much shorter title because of Wix size criterion as follows: Why Were Vital Human Factors Influencing the June 30, 2013, YH Fire GMHS Fatalities Never Revealed? is based on the 2021 Applied Human Factors and Ergonomics (AHFE) paper titled: How Many Human Factors Influenced the June 30, 2013, Yarnell Hill Fire 19 Fatalities And Yet Were Never Investigated nor Documented?


The AHFE paper was limited to eight pages. The headings and subheadings for this YHFR post are virtually the same with some additions. Only the numbering of those bolded headings and subheadings has been removed and replaced with letters and numbers instead, (e.g.. A. Abstract or D. Human Factors and D.1. Willingness to Properly Refuse Risk. Additionally, in the AHFE paper and this YHFR post, the bracketed source or reference numbers, such as [3], are placed after the text as the sources that correspond to the relevant reference materials at the bottom of the AHFE paper.


Sources in this YHFR post.will be cited at each relevant sentence or paragraph and links will be provided on the majority of them; some links would not post even after several attempts. The authors will attempt to also place links into each of the original AHFE paper in the references section.


 

A. Abstract.


Wildland firefighting is inherently dangerous, fraught with simple mishaps to inevitable fatal outcomes for the unwary. Established, sound rules and guidelines will continue to work to keep Wildland Firefighters and Firefighters safe. Human factors, consistent across all work groups, are variously broken down into human errors, human failures, error chain(s), etc. making fatalities unavoidable. All we can do is reduce them. Nineteen Prescott FD Granite Mountain Hot Shot wildland firefighters and supervisors perished on the June 2013 Yarnell Hill Fire in Arizona. Inexplicably, they left their Safety Zone during explosive fire behavior. A Serious Accident Investigation Team found, “... no indication of negligence, reckless actions, or violations of policy or protocol.” The authors and others inferred on an October 2013, YH Fire and GMHS Site Visit "Integration Phase" comment by a Senior HS Supt.: "... the final, fatal link, in a long chain of bad decisions with good outcomes." Among other things, tunnel vision, auditory exclusion, goal fixation, non-critical thinking, destructive goal pursuit, Groupthink, and "Friendly Fire" are discussed.


Keywords: Yarnell Hill Fire -Wildland Firefighting - Friendly Fire - Human Factors


B. Introduction


How is it possible that 19 wildland firefighters perished on the Arizona State Forestry (ASF) Yarnell Hill (YH) Fire in one fell swoop? In a word, it is "impossible." Yet one must question if the USFS federally-funded the Serious Accident Investigation Team and Report (SAIT-SAIR) and then boldly and unbelievably concluded that they found “... no indication of negligence, reckless actions, or violations of policy or protocol”? (emphasis added)[1, 2, 3] Additionally, “3. The Team recommends ... develop[ing]a wildland fire staff ride for the Yarnell Hill Fire incident. The staff ride is a process of conveying the lessons learned from this incident for future fire leaders.” Furthermore,“5. The Team recommends that the State of Arizona request the NWCG and/or Wildland Fire Leadership Council (WFLC) to charter a team of interagency wildland fire and human factors experts to conduct further analysis of this event and the wildland fire communications environment.” (emphasis added) [1, 2, 3]


A retired USFS wildland firefighter is attributed with saying: 'Once firefighter and investigator lies about fatality fires get written into official reports, staff rides only turn the lies into dramas. Even if the Truth later seeps out, the staff rides keep regurgitating the same original lies. ... [WFs] keep dying for the same reasons thus NWCG and all its ilk are truly guilty of negligent homicide. We lie to protect our imaginary personal, crew and agency images and real firefighters keep suffering and dying to nourish those collective fragile egos.' IAWF (2011)


Human factors refer to environmental, organizational and job factors, and human and individual characteristics, which influence behavior at work in a way which can positively or adversely affect safety. [5] The Staff Ride is a stellar idea, brought to fruition more from a mandated court order than from this SAIT recommendation. [4] However, it’s been reported that the “official” ones were fairly restrictive and required to use and follow the “official” SAIR, thus impeding any valid lessons learned. [4] And the inter-agency team of “human factors experts”? These were likely pretty obvious to the alleged "investigators" and discussed among themselves and those above them, but certainly never taken onto completion for true lessons learned. And so, the authors and interested others (e.g. InvestigativeMEDIA, Yarnell Hill Fire Revelations) took it upon themselves to accept and attend to this crucial task.[4] There will always be a continuing need for dedicated research on the Yarnell Hill (YH) Fire fatalities, seeking out and gathering newly revealed public records evidence regarding the causal human factors and human errors ignored in the alleged “investigation.” Some WFs, FFs, and slightly inquisitive others are still unsure whether there was a rogue firing (burning out) operation in the Sesame Street and Shrine Fuel-Fire Break Corridor(s). This is informally referred to in the insensitively-named Serious Accident Investigation Team “Factual and Management Report”(SAIT-SAIR) as the “the two-track road (an old fuel break) between Sesame Street and Shrine Road...preparing for burnout along the dozer line.”[3] Some GMHS family, friends, and loved ones, are grudgingly aware of it, and prefer to euphemistically (and incorrectly) refer to it as a “backburn.” [4] (i.e. “I stand firm that there was a back burn that came up that canyon. It was this fact along with the weather change that the IC never sent out because they were busy evacuating that caused the death of Granite Mountain.”) [4] This is a wishful yet out-of-place sentiment. Allegedly “evacuating” had nothing to do with their deaths! Undeniably, from their viable Safety Zone in the black, they had the best vantage point of anyone on the fire (except Air Attack) and the two eyewitness hikers (Tex Gilligan and Joy A. Collura), of the increasingly adverse weather and the resultant aggressive fire behavior that somehow deceived them. The GMHS veterans knew better! Because of all this, WFs, FFs, and others will continue to struggle to make sense of the June 30, 2013, YH Fire; the “how and why” 19 of the 20 Granite Mountain Hot Shot (GMHS) fatalities. We all certainly know how they died. However, there is a rightful need to analyze why so many died needlessly and why key evidence is concealed, impeding lessons learned; all the while restricting YH Fire-informed and YH Fire-knowledgeable USFS employees from talking about or legally being questioned for the tragedy.[4]




Figure 2. Intense fire behavior (6/30/13 at 1629 hrs.) from the Assembly of God church along Hwy. 89 with Google Earth overlay. Right icon is GMHS location, left icon is GMHS-descent point, lower icons are GMHS deployment / fatality site - Deployment Zone (DZ) and Helms / Boulder Springs Ranch (BSR) Source: Lauber, WTKTT, Google Earth.


Figure 3. Mary Nguyen Channel 12 News photo of intense fire behavior (6/30/13 at 1631 hrs.) along Hwy. 89. The GMHS Deployment Zone would be over the small foreground ridge at the base of the intense fire behavior and intensifying, darkening smoke column. Source: ABC News, WantsToKknowTheTruth (WTKTT)


The above Figure 3. image, in the words of WTKTT, "this may be the best photographic evidence yet of the YH Fire movement entering the box canyon, eight minutes before all the GMHS would be burned over."


Figure 4. Enhanced Google Earth snippet image using Paint. Aligned northwest, Sesame Street and Shrine Corridor (middle and upper right) leading up to the parallel twin chutes (middle) funneling upslope to the GMHS Deployment Zone - Fatality Site (upper left). Source: Google Earth, Schoeffler.


This above Figure 4. image basically represents a virtual upslope ' slingshot' that funneled extremely hot gases and exponentially intense fire behavior within the narrow confines of chimneys and chutes (venturi effect), directly into the broader deadly bowl where the GMHS deployed fire shelters and ultimately perished.


Figure 5. Google Earth Vertical Cross-Section snippet image, aligned northwest, the Sesame Street and Shrine Corridor (lower right) is leading up to the parallel twin chutes (middle) funneling upslope to the GMHS Deployment Zone - Fatality Site (upper left). Source: Google Earth, Schoeffler.


This idealized image represents the virtual upslope 'slingshot' that funneled extremely hot gases and exponentially intense fire behavior within the narrow confines of chimneys and chutes, directly into the broader deadly bowl where the GMHS deployed fire shelters and ultimately perished.


C. Background.


The magnitude and complexity of the fire itself and of the human response to it will vary because fire operations are inherently dangerous and will never change. [6] The risk to wildland firefighters (WFs) and Firefighters (FFs) has increased in recent years largely due to large fires having been located in the Wildland Urban Interface (WUI); an increasingly common and dangerous area “where structures and other human development meet or intermingle with wildland or vegetative fuels.” [7] Was there a rogue firing operation below the GMHS in the Sesame Street and Shrine Fuel-Fire Break Corridor areas that they were unaware of because they had no lookout or because they failed to notify Air Attack of their intentions and whereabouts? Or was it because those involved with the several separate firing operations never informed anyone of them performing burnout operations below them? It was very likely all of them. (emphasis added)


The authors believe that this was a clear sign of the normalization of deviance, drifting into failure; a progressive series of elements in a long chain of bad decisions with good outcomes setting up their inevitable fatal entrapment outcome.[1, 2, 4, 7-9] The following enumerated factors may well have impeded their decision-making: (1) cultural influences of municipal fire departments with collateral wildland fire responsibilities to “save structures” at all costs while considering "FF safety as a last resort;” [9] (2) known, obvious unsafe GMHS leadership concerns; (3) weak Crew cohesion that relied on consensus-seeking (“absence of leadership”); and (4) failing to know that the situation(s) were getting out-of-hand (snowball effect), thus losing the ability to detect that they were cognitively overloaded and needed to change plans or disengage. It is wn a situation starts small and gets built up increasing in power and momentum as it grows, and it can be negative or positive.



Figure 6. Decisions and Outcomes Matrix. Source: CAWRT PowerPoint snippet


Amazingly, at the July 2013 GMHS Deployment Zone News Conference, Prescott FD Wildland Fire Battalion Chief Darrel Willis, obviously attempting to ameliorate the situation and justify the GMHS' individual and collective actions, blatantly downplayed the significance of LCES and the required need to have a Lookout “they emphasized ... (LCES), ... ,however, there are points during that workday ... you don’t have all of those standards in place ... especially with them moving, ... you couldn’t leave anybody behind. ... wouldn’t have left anybody behind.


These men “died with honor, ... stuck together, ... saw / felt the same way”“protected themselves as a last resort... picked the best location in this bowl... “ Suggesting Groupthink here. And nowhere in any wildland fire training or annual refreshers does it encourage anyone to seek refuge in a bowl. It specifically cautions against deploying in chimneys and chutes.

.

He fallaciously asks this rhetorical question: “ ...**why do [FF] run into burning buildings** ...it’s ingrained in them... not going to sit up there in a Safety Zone when... potential for people to be at risk somewhere.” This is the **Fallacy of False Equivalence or False Analogy** and an enormous ‘leap’ from structure to wildland fire. ("they couldn't have left anyone up there;" He encouraged deadly Groupthink ("I would have followed them blindfolded into the place where they were at ... I'd have been right there with them"), encouraged leaving the safe black to engage and attempt to save structures ("no firefighter is satisfied sitting in the black, in a SZ watching the fire progress below them"), and he even deemed the tragic event as this is “an accident, just one of those things that happen.” Yeah, right! "Just one of those things that happen." All by itself it just happened? No blame, no fault, nobody made any bad decisions? Yet 19 GMHS died in one fell swoop! What a bunch of bovine feculence!


 

Consider now some further critical, causal human factors never revealed -


Stress matters. When ... stressed, ... inhibited in practicing new ways of acting. ..., relying on their most familiar habits.Daniel Goleman (2012)


Tunneling” or “Fixation–locking on to one explanation of your world –behavior is driven by events and difficult to anticipate and influence future circumstances. Dekker, Sydney (2000) The Field Guide to Human Error


In times of the highest stress, trained individuals fall back on their ‘highest level of overtraining’". Karl Weick -South Canyon Revisited. (USFS -MTDC)

 


Based on the above quotes, consider now some renowned fatal wildfires where this stress reaction influence was pervasive and manifested itself in the following ways:


South Canyon Fire (1994) CO BLM -14 fatalities - IC sharpening chainsaw instead of managing the fire and his resources

Thirtymile Fire (2001) WA FS - 4 fatalities - IC using hose and nozzle instead of managing the fire and his resources. NOTE: this was the final straw of being a Crew Leader while also performing as an Incident Commander as a collateral duty.

Yarnell Hill Fire (2013) AZ ASF, BLM, and Private – 19 fatalities – DIVS A and Acting GMHS Supt. refer to GMHS as “Granite Mountain 7” – formerly a Fuels Crew, i.e. “Crew 7” and DIVS A answering for GMHS instead of DIVS A in response to AA and being emboldened by their “ final, fatal link, in a long chain of bad decisions with good outcomes

 

OPS (PFD BC) radio briefing “Hold that line at all costs“ Thompson Ridge Fire SNF NM in May 2013. This statement by PFD Willis highly suggests giving one's life to hold the line. The Prescott Way?


Public Decisions - A factor that binds people to their actions is ‘going public’ when someone participates in and is identified publicly with a decision, that person will resolve inconsistencies to produce attitudes consistent with that choice.” The Challenger Launch Decision – Diane Vaughan (1996) The GMHS made a public decision to stay in place when ordered to go to Yarnell to assist. And then micro-public decisions on their discrete Crew Net channel to leave the black ("discussing our options." ) ( https://www.high-reliability.org/allied-knowledge-impediments )


The GMHS were "in the black" when the Yarnell Structure Group Supervisor called OPS and requested the GMHS to assist with Yarnell structure protection, while all other WFs and FFs were told to disengage antd stage at the Ranch House resaurant. At 1542 (3:42 PM) OPS requested the GMHS assistance. And the GMHS response was: “we are committed to the black, send BRHS, they’re already there.” OPS then reaffirmed that DIVS A and that GMHS in their SZ and in the black, and to HUNKER AND BE SAFE. The Group Supervisor also called the TFLD(T) to send two Engines to the BSR to meet GMHS coming down and to make sure GMHS ‘gets out of there safely." (emphasis added)


From TFLDT(t)

 

Esquibel’s Unit Log… ————————————————– 1445 ( 2:45 PM ) Met with Structure Group 2 ( Gary Cordes ). Plan to use TF2 ( Esquibel’s Task Force 2 ) resources to tie dozer line to rock outcrop on Mountain west of Shrine Road in Harper Canyon. Blue Ridge IHC AND Granite Mountain IHC ( BOTH Type 1 Hotshot crews ) to improve dozer line.

1632 ( 4:32 PM ) St Group 1 ( Cordes ) request (1) engine to Boulder Spgs. ( and also says to make sure Granite Mountain gets out of there safely ).


( https://www.investigativemedia.com/please-begin-yarnell-hill-fire-chapter-xviii-here/#comment-322869 )


The Structure Group Supervisor is incredulous and surprised when he was later informed that the GMHS had deployed fire shelters. “They had plenty of time.” The Structure Group Supervisor said he wasn’t surprised that Granite Mountain attempted to reach the BSR. (emphasis added) Source: ADOSH Interviews, September 11, 2013 and February 27, 2014


 

Doing it Right - Entrapment Avoidance


• Talk With Each Other/Discuss the YH Fire to Encourage and Foster Healing


• If You Are The Boss, Then BE The Boss ! Double SSOB!


• Know and Understand and Recognize ALL the WF Rules by Heart


• Give Leader’s Intent and Then Ask Resources For Input, Ideas, Suggestions to Avoid Groupthink


• Heed Watch Out #4 dealing with local weather and fire behavior factors


• Know, Understand, and Practice Sound Risk Management


• Learn to Properly Process All the Information You Receive


• ALWAYS HEED and DISCUSS INSTINCTS, INNER WARNING SIGNS, ‘GUT FEELINGS’


• Know How to Properly Refuse Risk (Turn Down Protocol) IRPG page 19


• If You See Something Say Something to Others AND Especially Your Supervisor(s)


• Use Direct Speech ! -Avoid Mitigating and/or Hinting Speech


• Speak Up If / When Uncomfortable With and/or Unsure of Tactics, Plan


• Avoid the Dangers and Traps of Groupthink


• Avoid ‘Going Along Just To Get Along’ with everyone else, i.e. Trips to Abilene


Source: Human Factors Influenced the June 30, 2013, YH Fire and GMHS Fatalities. Google Scholar

 

Major Phillip M. Johnson (2001) Effects of Groupthink on Tactical Decision-Making. Defense Technical Information Center


Major Johnson stated that the way to almost guarantee Groupthink was to give Leader's Intent and then tell your resources what he plans to do, because most people will want to do what the Boss wants to do. And then he stressed that the way to avoid Groupthink was to give Leader's Intent, then ask your resources what they think should be done. Thus giving them some ownership in the decision.


Jerry B. Harvey – Abilene Paradox (1996) Abilene Paradox is a phenomenon that describes a situation in which a group makes a collective decision that does not correspond to the feeling and thoughts of the individuals in the group.( https://www.talentlyft.com/en/resources/what-is-abilene-paradox ) ( https://images.app.goo.gl/YSPuxQD7xUH61FfAA )


Malcolm Gladwell – OutliersMitigated Speech - addressed in A Missing Plane, Mitigation Speech and The Fire Service (Part 1) On the Fire Ground by Grant Schwalbe (Mar 14, 2014)


  • Command: “E43 will stretch a 2 1/2” line through the Bravo side door” (Very direct)

  • Crew Obligation Statement: “I think we may not want to do our normal Alpha-side stretch here”. (Softer statement and use of “we”.)

  • Crew Suggestion: “Let’s try to attack from the unburned side.” (We are deciding together.)

  • Query: “Where would you like me to stretch the line since we aren’t going in the front?” (Speaker is conceding that he is not in charge.)

  • Preference: “I think it’d be wise to should stretch the line someplace other than the Alpha-Side”

  • Hint: “This doesn’t look like our typical stretch at a fire.” (Outliers, p 194-195)



Figure 7. July 2013 GMHS DZ News Conference Source: YouTube, IM John Dougherty


Figure 7.1. July 2013 GMHS DZ News Conference Source: YouTube, IM John Dougherty


D. Motivation.


A retired USFS wildland firefighter wrote: Generally, the goal of accident reports is to convey as much of the truth of an event that is discoverable. Sometimes investigators deliberately distort or do not report all the causal elements, leading firefighters to distrust these reports, which can hamper our efforts to stay safe. [4, 11] ‘Wildland firefighting is a high-risk occupation, shown each year by deaths or injuries in the line of duty. Identifying causal human factors to mitigate them in the future is critical.’ [6] The authors allege the USDA has been exceptionally deceptive. Given all this, one has to ask how are true, intended complete “lessons learned” possible? Veteran WF Bruce Hensler points out that it does no good to identify or share any “lessons learned” if the industry that needs to learn them refuses to do so.[12] Hensler noted: "[A retired USFS wildland fire fighter] believes wildland firefighters will continue to die as long as they fail to acknowledge and come to terms with certain realities by acknowledging the trap of a can-do spirit; unwise agency cost-control measures; image of self, crew and agency; and the recurring failure to learn from lessons." [12] However, it should be attributed to Hensler [12] and will be corrected here, because this was incorrectly cited as [11 - Accidents, accident guides, stories, and the truth. IAWF] in the original AHFE paper.


NOTE: The authors shared this post in draft form with [A retired USFS wildland fire firefighter] for the several references and quotes from him that are cited here. He took issue with some of what Hensler stated in his Fire Rescue article (2019) titled Yarnell Hill: The Human Factor .' [A retired USFS wildland firefighter] wrote: "There are problems with what Hensler says that can' be easily addressed. Some are false and misquoting me! ..." The YHFR lead author encouraged a retired USFS wildland fire fighter to submit a comment to the article and that we would place his comments in this post.


E. Fullness of meaning - We no longer have so-called "investigations" anymore and instead have the latest vouge replacement of "no blame, no fault" Facilitated Learning Analysis (FLA), Coordinated Response Protocol (CRaP), Learning Reviews, Learning From Unintended Consequences, and the like. It is interesting to note that most - not all - of this cadre of alleged "experts" are the ones giving us less than the truth on these incidents. "It's just an accident, one of those things that happens" mentality. So then, how can instructors and supervisors honor the fullness of meaning in those involved WFs' and FFs' experiences, involvement, discussions, decisions, actions, etc. that led to the unfortunate outcome. Instead, it's been replaced with stories ("tell us your story") because we do no more statements. Why? Because those are considered too harsh and invasive. Whatever. And so, we must ask - what benefit is there in doing so? Hensler also stated: "While investigation reports tend to distill incident details down to the facts and figures, it is the more elusive human factor that is perhaps most telling when trying to understand decision-making – and determine lessons learned." (emphasis added)


The verb "decide" has deadly interesting origins. Though it came through Middle English deciden, Old French decider, and Latin decidere, you can tell that there's the prefix de-, kind of meaning "off". This was in the language as far as etymologists can trace it, and is either from Etruscan or Proto-Indo-European. It's the other part of decide that's surprising: -cide. Yup, as you may have guessed, this is the same -cide present in words like homicide, suicide, regicide, fratricide, genocide, and all those other euphemistic terms for nasty kinds of death. All the roots trace to the Latin verb caedere, meaning "to cut". The death-related words are connected because of the correlation between "cut" and "kill", a side meaning which later evolved from the word, and decide is connected because when you make a choice, you cut out all the other possible choices. So it sort of makes sense, right? Caedere comes from Proto-Italic kaido, from Proto-Indo-European kehid, which meant something more like "strike". Theentomologynerd


This should certainly give one pause and a different perspective on decision-making, ey.

 

F. The Sesame Street and Shrine Fuel / Fire Break Corridor Area(s) Firing Operations


At least twenty (20) people, including veteran WFs and FFs and the two YH Fire eyewitness hikers watched a video in July 2013 at the Yarnell, AZ Library of a Sesame Street and Shrine Corridor firing operation; also viewed by one FF on YouTube before it was removed. The video abruptly vanished without a trace, like other YH Fire evidence. There were also burnt fusees (firing devices akin to large road flares) found on a 2014 site visit and a GMHS family member found “accelerants” with local-area specialized dogs another time.[4] Former YFD Fire Chief Peter Andersen (RiP) validated this with his statement: “we built an emergency escape route for Yarnell in case there was a burnout like this... in that area below The Shrine, west of The Shrine, they had dozers back there widening that so that it would create a fire break, ... ” [13] These WFs and local FFs regarded it as so, and they rightly acted accordingly and utilized the Corridor for one of the firing operations discussed in the SAIT-SAIR.

Figure 8. Former Yarnell Fire Chief Peter Andersen (RiP) describes the Arizona Forestry Division's response to the Yarnell Hill Fire that killed 19 Granite Mountain Hotshots on June 30, 2013. Source: YouTube, IM John Dougherty

 

These particular excerpts (below) deal with radio conversations between DIVS A Eric Marsh and DIVS Z Rance Marquez and his Strike Team Leader (T) Coughan Carrothers and their locations, decision-making, and actions during at least one of the possible ostensibly rogue firing operations along the Sesame Street - Shrine Corridor areas on June 30, 2013. They come from the SAIT and / or ADOSH interviews and interview notes. (https://www.investigativemedia.com/yarnell-hill-fire-chapter-xi/#comment-259128 )


Marquez: "Um, [Marsh] understood what I was saying, but he had about two other radios going off in his ear plus other things going on, so he just said, 'Yeah. Um, we’re off – we’re going to have uh, at a later – later time.' and started to prioritize information." (emphasis added)


This statement by DIVS Z Marquez about DIVS A Marsh is verified as a fairly strong distraction from the Tunnel Vision and Auditory Exclusion research (John Hopkins) discussed in the relevant Human Factors section in G.9. (below).


IM Marti Reed - "My problem is that, since this visual scenario doesn’t correspond with what Carothers and Marquez told ADOSH, I’m not all that convinced their story about what they did over at Sickles Road is true. And that ties in with that photo of Carothers’ truck up there on the Dozer Line above Sesame at 10:12 on Sunday Morning. There’s just too much that doesn’t connect between their visual footprints and their stories.That’s been bugging me all along……"

( https://www.investigativemedia.com/yarnell-hill-fire-chapter-xi/#comment-247647 )


 

The Prescott Daily Courier - A Narrow escape: Peeples Valley firefighters recount that frightening day. Published: 6/30/2014 6:00:00 AM by Joanna Dodder Nellans


( https://web.archive.org/web/20140805112142/http://dcourier.com/main.asp?SectionID=1&SubsectionID=1&ArticleID=133345 ) Internet Archive Wayback Machine link because the IM link was no good. ("Page not found. The requested page could not be found").


The authors took some minor liberties combining some short sentences into the paragraphs above them. (all emphasis added below)


YARNELL - Bob Brandon and Ron Smith feel lucky to be alive after running for their lives from the Yarnell Hill wildfire.


They were among the Peeples Valley firefighters working in a valley on the west edge of Yarnell, only about three-quarters of a mile from the site where the flames overran 19 Granite Mountain Hotshots and killed them on June 30, 2013.


Four Peeples Valley firefighters, two from Wickenburg and two from Sun City were cutting a line between the wildfire and the town of Yarnell on that fateful day. It was the same line that the Blue Ridge and the Granite Mountain hotshot crews were helping to build.


When Brandon and Smith arrived on the property near the Shrine of St. Joseph that day, the blaze was threatening their own community of Peeples Valley to the north instead of Yarnell. They figured they would just be doing mop-up work.


The Blue Ridge Hotshots and the eight men from Yarnell, Wickenburg and Sun City came together from different directions at about 2:30 p.m. and followed a bulldozer to improve the line behind it.


The dozer apparently was unable to cross a deep ravine and turned around. The eight men from Yarnell, Wickenburg and Sun City had to cut through the last quarter-mile or so of dense oak, catclaw and manzanita on their own. Brandon said he later found out from the dozer operator that he left not because of the ravine, but because he had been warned that the fire changed course. The Blue Ridge Hotshots left about the same time, Brandon said.


Capt. Brandon had placed Peeples Valley firefighter Matt Keehner as a lookout on a hill of boulders where the fire line was supposed to end. The hill was between the firefighters and the fire. About 3 p.m. Keehner came down, telling Brandon he heard on the radio about a change in the weather but he was unclear about the nature of the change.


Smith said he stopped for the hourly weather report at 3 and heard the wind was shifting to the east, but he never heard later that the wind shifted again to the southeast.We didn't think we were in immediate danger, or they wouldn't put us in there," Smith said.


Brandon, who was stationed with the vehicles, noticed an air tanker stopped dropping retardant on an east-to-west line and moved to a north-south line. Brandon and Keehner decided to move their water tender and engine away from the thick brush and closer to the house on the property.


Brandon was in shock when he got out of the water tender and looked up in the sky at about 3:45 p.m.


"The smoke and fire was going straight up and I thought, 'Holy crap,'" he related. The flames on the other side of the 60-foot to 70-foot-high hill where Keehner had stood were twice as high as the hill, and they were coming toward the firefighters.


"The heat was just tremendous, it was like waves," he said. "All the tops of the trees just went 'snap snap snap' like that on fire." Brandon feared his fellow firefighters would have to deploy their shelters. The fire was too loud to talk. In the midst of the chaos, he texted them and they said they were OK.


Their group supervisor pulled up and told Brandon and Keehner they had to move their trucks out. Brandon refused, telling the commander that his crew was still in there. The supervisor repeated his order, saying the other guys couldn't run that fast.


Brandon didn't want to think about what the supervisor meant. randon and Keehner followed the order, but tried to move as slowly as possible as they turned on the trucks and headlights.


They went about 100 feet to the shrine parking lot and waited at the end of the ravine, hoping their buddies would run straight to them through the sandy gulch. They decided they wouldn't go any farther until they saw their buddies. Then they spotted them running down the road, followed by the Wickenburg and Sun City vehicles.


"It happened so fast," Smith said. He credits fellow Peeples Valley Capt. Jake Moder with saving his life by keeping a close eye on their situation while they were digging and cutting the line. While they were building the line, Moder saw the hill to the north catching fire. Smith knew it was time to run when he saw Moder's face as he ran toward him about 4 p.m.


"We felt impending doom," he recalled. "We were literally running and it was coming at us fast. You could feel it burning the hair on the back of your neck and sizzling your arms. "I didn't think we were going to make it."


They ran down the ravine about 100 yards and were angry when they realized the trucks were gone. But when they cut over to the paved road, they felt like they were going to survive."We were probably two minutes from becoming a statistic," Smith said. "You'd have a memorial here for us."


They ran down the paved road toward their safety zone at the shrine parking lot. The Wickenburg and Sun City firefighters offered them a ride but they could see their own trucks by then.


Smith said he realized that his buddies might have saved his life by moving the trucks, because that kept him and Moder from trying to stop and get the vehicles. It's likely they already would have been burned up, Brandon added.


At their shrine safety zone, they heard on their radios that the fire had breached one of the evacuation trigger points but they didn't know which one. They were supposed to have an hour from one of the trigger points to evacuate; they got about four minutes.


They heard 19 firefighters were unaccounted for, but they didn't imagine they were dead. They thought their group supervisor might have worried it was them, since he came back up the road.


They were parked at the shrine when the fire blew over the edge of the parking lot and on over the hill to the southeast. Then they met up with other firefighters at the Ranch House Restaurant on the east side of Highway 89 and saw the flames jump the four-lane highway.


"It was just like being in a war," Brandon said. Someone wanted to set up a triage for potential burn victims but others figured it couldn't be a good spot for that because of all the falling embers and smoke.


"It was like trying to breathe through the thickest, rottenest smoke in your life," Brandon said. "It was just soup." Despite covering his nose and mouth with his shirt, Brandon felt his nose and throat burning and knew he had to get away.


On the way from the restaurant parking lot to the incident command post, the firefighters heard that some firefighters were missing. At the IC post, they heard the firefighters died while deploying their shelters, and then later that night they found out it was the Granite Mountain Hotshots.


The next day, Smith and Moder helped put out spot fires on a dozer trail built for investigators to access the site where the hotshots died. Smith later served as an honor guard at the scene, while Brandon and Moder helped close off the area.


Brandon and Keehner helped douse structures and extinguish spot fires in Yarnell, including a burning manzanita right next to his friend's house. Keehner's parents lost their home.


Brandon suffered injuries to his nasal passages and throat in the blaze. He couldn't breathe at night and often ended up trying to sleep in a sitting position. He tried to be tough and use nose drops but that only made it worse. His nose became red and swollen and his voice sounded like gravel.


He tried to deal with the issue on his own while he oversaw the Yarnell Recovery Group's efforts to rebuild uninsured homes lost in the fire.


He finally gave in and filed a medical claim with the fire department about six months after the fire. He underwent surgery to remove polyps from his nose on May 27.


He still has a sore nose and throat and bowed vocal cords, he has to use a steroid spray, and he has to wash out his sinuses twice daily. But he can breathe.


Smith's injuries are more psychological. He knew the Granite Mountain Hotshots from various training courses, and GMHS Supt. Eric Marsh was among his instructors.


"These guys will be remembered for lifetimes," he said. "They'll change the way fires are fought.


"It really brought a lot of people together. It tore some apart, too." For Brandon and Smith, it brought them together. "I'd follow Bob into a dirty bathroom and mop the floor," Smith said. "He's my mentor."


Brandon, a former Peeples Valley fire chief who helped start the department, hopes that one of the lessons learned from the fire is that fire commanders will listen more to local firefighters.


He said Peeples Valley firefighters wanted to hike in and put out the Yarnell Hill wildfire the day lightning ignited it, but were told to stand down. Smith said the Yarnell Hill fire taught him to pay much closer attention to the weather on the fire line.


"I will always be on top of it now," he said, noting he took a weather class at the Arizona Wildfire Academy this year. "We knew the fire was going toward Peeples Valley, and we never thought about it coming back on us." (all emphasis added above)


There are some serious problems with this article; and Bob Brandon's statements based on other YHFR posts, that strongly suggest that the PVFD were purportedly very active participants in this particular, possible firing operation.


 

Consider now Parts One and Two - Who Do We Continue to Distinguish And Read About as the Likely Participants in the Undeniable Sesame to Shrine Corridor Fuel / Fire Break Possible Firing Operation? in the two links below.


( https://www.yarnellhillfirerevelations.com/post/2018/08/06/who-do-we-continue-to-see-and-read-about-as-the-likely-participants-in-the-strongly-infer )


( https://www.yarnellhillfirerevelations.com/post/2018/08/18/part-2-of-who-do-we-continue-to-distinguish-and-read-about-as-the-likely-participants-in )


On February 6, 2015, IM Marti Reed states: "I’m still not completely trusting Bob Brandon’s account, given what’s in the video. His water tender comes out at a pretty fast pace (“Slow down, Skippy”) right before the Blue Ridge Buggies. There’s no Aaron video of the Blue Ridge Sup Truck or any of the [four] Granite Mountain Trucks coming out. And after him a SIGNIFICANT number of other vehicles are shown coming out. This whole thing just doesn’t square to me, given what I’m seeing." (emphasis added)


 

F.1. Local FFs involved in the Sesame Street and Shrine Fuel / Fire Break Corridor Area(s) Firing Operations?


The following excerpts are from the USFS Apprenticeship Academy in CA during a S-290 Intermediate Fire Behavior training course on the subject of Extreme Fire Behavior and the June 30, 2013, YH Fire in particular. There is a FF that was on the PVFD as a student at the Academy and qualifies as an eyewitness. A USFS employee was leading a S-290 course discussion on Extreme Fire Behavior using the June 30, 2013, YH Fire as an example.


"Firing out multiple spur roads ... Wanted to keep it square so it would not jump over the main road. FF asked supervisors if everyone was out of the way before we did this, including civilians. The only supervisory affirmation he got was: 'sometimes we do things that we have to, not because we want to.' The FIRB was ‘part of the set-up,’ part of the IMT before we got there, someone like a Structure Protection Specialist.’


‘We had the engine out in front of us [reveals inexperience of Municipal FD and FFs]... No spots, absolute miracle because the wind was howling parallel with the road they were on and every now and then it would gust over the road and throw embers -but no spots ... and the Engine was going fast and we had a hard time keeping up with it.’ ‘The urgency and fear in the eyes of everyone on that road was unnatural. It was burning in so fast ... ripping right in. They tied into a corner, a bunch of vehicles came out including BRHS and the GMHS buggies ... [he started crying again].... we felt much better lighting to the corner of this road / intersection, and because we saw GMHS rigs, we figured they were inside, out of the area.’


‘The fire was gone, half mile or mile away from us within 5-10 minutes of firing, uphill and gone. ...We all staged in our rigs listening to the TAC channels and then we heard the GMHS and A/G chaos.... The entire [Engine] Crew, including our Captain, felt like there was no air in the Engine, like we couldn’t breathe. ... Our Captain said he felt like he was gonna have a panic attack ... We heard our Captain say:'We just f**king killed people.”’


‘He got a direct phone call from a high-level supervisor telling him not to talk with anyone else about the YH Fire and told him if he spoke about the YH fire one more time to anyone he would be sent home.’‘ He felt ostracized for the rest of the academy because people made sure he would not talk about the YH Fire ... And he is still traumatized by it.'


 

Figure 9. Dr. Leroy Anderson June 30, 2013, video compilation. Source: Anderson, Collura, YouTube


Numerous photographs with accompanying metadata of separate and distinct smoke columns indicating possible firing operations along the Sesame Street - Shrine Corridor areas


Figure 9.1. Dr. Leroy Anderson June 30, 2013, video compilation. Source: Anderson, Collura, YouTube


Numerous photographs with accompanying metadata of separate and distinct smoke columns indicating possible firing operations along the Sesame Street - Shrine Corridor areas

_______________________________________________________________________________



G. Wildland Firefighting Rules - Human Factors, Human Errors, and Human Failures


All WFs are trained in specific rules, crucial to follow to ensure good direction, leadership, safety, and vigilance. The strict Standard Fire Orders, organized purposely and sequentially, are to be carried out sensibly on all wildfires.[1, 2, 3] The 18 Watch Out Situations, (i.e. guidelines), are faced on all fires, more to warn of impending dangers. The authors and experienced WFs contend that knowing and abiding by the wildland firefighting rules works. They urge sound leadership and safe decisions.[6] There are no documented wildfire fatalities when the Standard Firefighting Orders are followed and the cautionary 18 Watch Out Situations (10 & 18) are mitigated.[14] Sadly, there is a crusade afoot by current and former WFs and Managers to discredit these based on the SAIT conclusion, i.e. “they did everything right and still died.”[4] The most critical of the established Wildland Fighting Rules are listed in the (NWCG) Incident Response Pocket Guide (IRPG).[1, 2, 15 ]Again, if WFs follow the Standard Firefighting Orders and are alerted to the 18 Watch Out Situations, much of the risk of firefighting can be reduced saving tens of thousands of WF lives each fire season. [1, 4] It is well-known and accepted in the WF community that these tried and tested rules work when applied consistently and with sound, decisive judgement.[1, 2, 4, 6, 9 ] (all emphasis added)




Figure 10. WFSTAR: Fire Orders (undated ) Source: NIFC NWCG WFSTAR


The NWCG, NIFC, and WFSTAR have shamefully stooped to new lows! They clearly lowered their standards by creating this immature and inane nonsense video in Figure 10.a. (below). Here is my posted comment on this crap from a year ago. No wonder we continue to have WF and FF burn overs, entrapment, and fatalities with clap-trap like this undated video. Who TF comes up with this feculence? Was this where GMHS McDid-Not came up with his Third-Year Crewmember Fire Order #10 being "Hillbilly" statement? Or was this video made because of alleged GMHS "lookout" Mc Did-Not's statement? (emphasis added)


Figure 10.a.WFSTAR Fire Orders Source: NIFC, YouTube


Figure 11 Wildland Fire LLC Honor the Fallen Source: WLFLLC, YouTube


My comments are in upper case and the WLF LLC comments are all lower case: As a former Hot Shot Superintendent, I confidently weigh in with Travis Nelson about the GMHS Superintendent's decisions and actions on June 30, 2013, and with Joy A. Collura on this one. You all need to visit the website: ( www.yarnellhillfirerevelations.com ) I took the time to re-watch the video in detail and transcribe the respective commentaries of these featured supposed "leaders. Their comments are in regular font and my comments will be in all CAPS below. The subtitle of the video states: “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.THERE IS NO "DISCUSSING THE CHALLENGES FACING THE WILDLAND FIRE SERVICE AS A WHOLE" FROM WHAT I HEARD. ONLY THE OPINIONS OF THESE OSTENSIBLE "LEADERS." I ALLEGE THAT THIS WILL DEFINITELY MISINFORM THE MANY WFs AND FFs THAT WILL GO ALONG TO GET ALONG BECAUSE OF WHO THESE PROFESSED "LEADERS" ARE AND WHO IS PROVIDING THE VIDEO AND THE ALLEGED "LESSONS LEARNED." AND I ALLEGE THAT THIS WILL DEFINITELY MISINFORM THE PUBLIC THAT DOESN'T KNOW ANY BETTER. Student of Fire - Hallowed Ground - Sense-making - Self reflection – Learning THE VIDEO BEGINS WITH THESE WORDS STREAMING ACROSS THE TOP. THE "SENSE-MAKING" AND "LEARNING" AS DISCUSSED IN THE VIDEO ARE INDEED INACCURATE BECAUSE THESE SUPPOSED 'LEADERS" ARE DISINGENUOUSLY ATTEMPTING TO CONVINCE YOU THAT YOU ARE AT THE MERCY OF NATURE, NOTHING YOU CAN DO SAVE YOU, EXCEPT LUCK, AND THAT THE LONG-ESTABLISHED VIABLE WF RULES AND GUIDELINES (10 & 18) "CANNOT KEEP US SAFE ... WHATEVER THEY ARE." HOPEFULLY, THIS VIDEO WILL ANGER YOU AND COMPEL YOU TO CALL BS ON ALMOST ALL OF IT. Travis Dotson (Wildland Fire Lessons Learned Center, NPS – Analyst, Former Hot Shot and Smokejumper) “… and everything about this fire, the communication, the situation with the weather; Resources, number of resources, lack of resources; Nothing on the next step to that is that if that stuff’s all normal, including the decisions, which I say that they are, then this outcome is normal and I don’t think we’re willing to make that leap but that’s that’s what logically that’s where that goes to and I hate that, but I think that’s what’s been staring us in the face for years and we’re not, we’re not willing to go there. It’s scary, you’ve got ten of us in violent agreement just …” MR. DOTSON, I TOTALLY AGREE THAT THIS FIRE, THE COMMUNICATION, THE SITUATION WITH THE WEATHER, RESOURCES, NUMBER OF RESOURCES, LACK OF RESOURCES, IS ALL NORMAL, INCLUDING THE DECISIONS. THEN THIS OUTCOME IS NORMAL BASED ON THE DECISION-MAKING HISTORY OF THE GMHS. AS DOCUMENTED, ONE SOUTHWEST HOT SHOT SUPERINTENDENT STATED ON AN OCTOBER 2013 YH FIRE SITE VISIT: "THIS WAS THE FINAL, FATAL OUTCOME OF A LONG CHAIN OF BAD DECISIONS WITH GOOD OUTCOMES, WE SAW THIS COMING FOR YEARS." THERE ARE MANY OF US WHEN THIS FIRST OCCURRED, AND TO THIS DAY, THAT READILY MADE AND STILL HOLD TRUE TO THAT LOGICAL LEAP. YES, IT HAS BEEN STARING US IN THE FACE FOR YEARS AND IT'S UNFORTUNATE THAT YOU ARE NOT WILLING TO GO THERE. SCARY FOR YOU MAYBE. WHAT IS SCARY FOR ME IS THAT YOU ARE AFRAID TO ADMIT IT AS THE LEADERS THAT YOU CLAIM TO BE. YOU CLAIM THAT THERE ARE TEN OF YOU "IN VIOLENT AGREEMENT" YOU SAY. WHAT DOES THAT MEAN TO BE IN "VIOLENT AGREEMENT" - FOR THOSE OF YOU WITH THE STONES TO FOIST THIS VIDEO ON US? Curtis Heaton (USFS - Director Safety, Fire and Aviation Management - R2,RO, Renewable Resources; former Hot Shot and NIMO OPS) “… just focus on, on perception and how hard it is to see what you need to see, no I’m saying how easy it is to see what you want to see, and no one person or one unit can do that; it takes the whole collectiveness of the organization, whatever it is Type 4, Type 1 to bring all those different perceptions into something that looks like reality, and we really have to revisit who we are, why we do what we do and how we prepare people exactly what we do you …” MR. HEATON, YOU START OFF SO WELL, MAKING YOUR CASE ABOUT PERCEPTION, THEN YOU FALL STEEPLY INTO THE FALSE CHASM WITH THIS ASSERTION THAT "NO ONE PERSON OR ONE UNIT CAN DO THAT; IT TAKES THE WHOLE COLLECTIVENESS OF THE ORGANIZATION ... TO BRING ALL THOSE DIFFERENT PERCEPTIONS INTO SOMETHING THAT LOOKS LIKE REALITY." THERE ARE COUNTLESS INFORMAL AND FORMAL CASES OF INDIVIDUALS AND UNITS DOING JUST FINE IN THIS MATTER FOR YEARS. AND WHAT IS EVEN WORSE, I CONTEND THAT YOUR COMMENT HERE ALIGNS QUITE CLEARLY WITH THE INSIDIOUS GROUPTHINK, ONE OF THE MANY ACKNOWLEDGED AND DOCUMENTED CASES OF HAZARDOUS ATTITUDES IN OUR IRPG AND ELSEWHERE. Steve Gage (USFS - Assistant Director - Operations for Fire and Aviation Management - Boise, Idaho Area - NIMO Incident Commander (May 2008 – Oct 2012) NIMO Incident Commander – (2008 – Present) Department of Homeland Security (FEMA) - USFS - NIMS Liaison - Department of Homeland Security (FEMA) (2005 – 2008) - Kern County Fire Department (Fire Chief) (Sep 1973 – Dec 2003) “… you know when we were standing up there you know and coming back down my perception of what I envisioned was going on in my mind’s eye was I’d have been right there, I’d have been coming down this road. I’d have been trying to fall off there and find a good sweet spot to get to, and that you know that whole concept of but for the Grace of God. You know how many times have … I been know that close and just barely got by and Mike’s about minutes you know cuz I was a minute ahead of it I was a minute behind it, whatever that was and you know my reality sometimes is I don’t understand why this didn’t happen more often, because the enemy, the force of nature that we’re dealing with is not as predictable as we think it is. We think we know it but we truly don’t.” MR. GAGE, YOUR COMMENTS ALIGN WELL WITH THE INSIDIOUS GROUPTHINK WITH YOUR "I'D HAVE BEEN COMING DOWN THAT ROAD. I'D HAVE BEEN TRYING TO FALL OF THERE AND FIND A GOOD SWEET SPOT TO GET TO ..." AND WHAT WAS WRONG WITH THE "SWEET SPOT" THAT THE GMHS HAD IN THEIR PERFECTLY VIABLE SAFETY ZONE? IT'S QUITE DISTURBING TO KNOW THAT YOU HAD BARELY MADE IT TO SAFETY ON NUMEROUS FIRES, NUMEROUS TIMES "A MINUTE AHEAD OF [THE FIRE] AND YOUR "A MINUTE BEHIND IT, WHATEVER THAT WAS" COMMENT IS VERY PERPLEXING BECAUSE EVEN YOU DON'T KNOW WHAT YOU MEANT OR EVEN EXPERIENCED "IN [YOUR] MIND'S EYE." IT'S DISTURBING THAT YOU ARE IN THE POSITION OF AUTHORITY AND PROFESSED "LEADERSHIP" YOU ARE IN WITH THESE COMMENTS.


Matthew Carroll (USFWS Assistant Fire Management Officer at North Country Fire Management - McCall, Idaho - Project Lead, Office of Innovation and Organizational Learning (2014 - Jan 2017) - R4 Fire Program Outreach and Recruitment Coordinator (2010 - 2015) McCall Smokejumper Base, McCall, IDA Group designed to foster a resilient workforce, advance innovation, and promote a culture of learning at the individual, group, and organizational levels within the USDA Forest Service YOU STATED: “… anytime we, we begin to interact with a force of nature this time, this forest fire that there .. it is complex enough that no matter what we throw at it process wise or intelligence wise or leadership wise that it will always outpace us, and I don’t know, I don’t that then backs us up to a conversation with the public we serve, it backs us up to a conversation with [the Agency we’re part of] and it’s a bad uncomfortable conversation scripted over a 100 plus years.” MR. CARROLL, YOUR'S, AND ALL THE OTHERS REGARDING THE COMPLEXITY OF THE "force of nature" AND HOW IT WILL OUTPACE US AND OVERWHELM US AND ALL THE OTHER FATALIST COMMENTS ARE QUITE BAFFLING BECAUSE THERE ARE COUNTLESS WFs AND OTHERS THAT HAVE BEEN SAFELY AND SUCCESSFULLY FIGHTING FIRE FOR MANY YEARS IN SPITE OF IT ALL. Heath Cota (USFS - Director Wildland Firefighter Apprenticeship Program - S&P-WO, Fire & Aviation Mgmt) “How complex our environment is … and the truth is that we try to put it into these little boxes in these rules and the 10 and 18 that cannot, they’re not gonna keep us safe, that’s been proven time and time again, we can’t follow our own rule, you know, these rules whatever they are, this environment, it’s way too complex. We’re really lucky, we do a good job at it and I think that to that was luck, the, the whole luck decision conversation, like ah, how often is it luck … ten minutes, five minutes earlier in a departure … we wouldn’t be standing here [like Mike said] um, truth is that it’s … this is gonna happen again next year, this Summer … somewhere, maybe not to this magnitude, right? But as long as we’re engaging in wildland fire I think we need to take the honest look and evolve how we’re dealing with it and take a look at ourselves, our culture, our organization, all those things. How we’re doing. The gravity of walking down that, I mean it, that’s where it hit me like a ton of bricks up there; looking down seeing it, how close it looks and how far it is, scurrying through that is, that’s where it hit home for me. And ah we can all see the … the path, the friction, the uncertainty, the fluidity in the environment and how it just shapes it to the point where this is absolutely feasible and possible like it’s at that time .. it was good … until it wasn’t.” MR. COTA, AS A FORMER HOT SHOT SUPERINTENDENT AND THE WASHINGTON OFFICE USFS DIRECTOR OF THE WF APPRENTICESHIP PROGRAM, THE ENTITY THAT TRAINS THE INCOMING, NEW USFS EMPLOYEES, YOUR COMMENTS ARE ESPECIALLY DISTURBING, ESPECIALLY YOUR OPINION ON THE "truth" ABOUT THE TRIED-AND-TRUE WILDLAND FIREFIGHTING RULES, THE 10 & 18. "... the truth is that we try to put it into these little boxes in these rules [sic] and the 10 & 18 that cannot, they're not gonna keep us safe, that's been proven time and time again, we can't follow our own rules you know, whatever they are, this environment, it's way too complex" AND THEN YOUR SPEW ON "luck" AND "luck decision conversations." ARE YOU KIDDING ME? AND WHAT WERE YOU AND YOUR HS SUPERVISORS TEACHING YOUR YOUNG WFs AS A HOT SHOT SUPERINTENDENT"LEADER?" I AGREE WITH YOU - IN PART - WHEN YOU STATE: "... that's been proven time and time again that we cannot follow our own rules." HOWEVER, THAT STATEMENT ONLY APPLIES TO THOSE THAT REFUSE TO FOLLOW THE BASIC WF RULES. TENS OF THOUSANDS OF WFs AND FFs SAFELY AND SUCCESSFULLY FIGHT WILDLAND FIRES EVERY YEAR BY UTILIZING THE 10 & 18 AND LCES. I CHALLENGE YOU TO PROVIDE ME EVEN ONE FIRE WHERE WFs OR FFs WERE ENTRAPPED, BURNED OVER, DEPLOYED FIRE SHELTERS, OR DIED BY FOLLOWING THE BASIC WF RULES AND LCES. THEN YOU SNAP BACK TO REALISM AGAIN - TEMPORARILY - AND CORRECTLY POINT OUT THAT WE NEED TO "take a look at ourselves, our culture, our organization, ... " I COMPLETELY AGREE. THE "evolve how e're dealing with it" LOST ME AGAIN IN THE FOG OF YOUR REASONING. SO THEN, IF SOMETHING "EVOLVES", THEN IT CREATES ITSELF AND WE CAN JUST LEAVE IT ALONG AND IT WILL FIX ITSELF, RIGHT? MY FAVORITE IS THIS GEM: "... it was good ... until it wasn't ..." REALLY? WTF DOES THAT MEAN? I HOPE AND PRAY THAT YOU ARE NOT INDOCTRINATING OUR NEW WFs WITH FECULENCE LIKE THIS. THE VIDEO CLOSES WITH THESE WORDS STREAMING ACROSS THE TOP OF THE SCREEN: "Honor the Fallen - Learn." I ALLEGE THAT YOU ALL ARE DISRESPECTING THE FALLEN AND THE LIVING WITH THE STATEMENTS AND CLAIMS YOU HAVE MADE AS SUPPOSED "LEADERS" IN THIS VIDEO YOU MADE. AND TO LEARN WHAT? PONTIFICATING - NOT "DISCUSSING" - YOUR OPINIONS THAT DO NOT ALIGN WITH "THE CHALLENGES FACING THE WILDLAND FIREFIGHTING SERVICE AS A WHOLE." THE WILDLAND FIRE LESSONS LEARNED CENTER CLAIMS: “A Lesson is Learned When We Change Our Behavior.” THIS IS A TRUE STATEMENT, HOWEVER, I ALLEGE THAT WITH THE STATEMENTS MADE IN THIS VIDEO BY THESE PROFESSED "LEADERS," THAT THE MAJORITY OF THE WF SERVICE WILL FOLLOW LOCK-STEP WITH WHAT YOU ALL HAVE PRESENTED HERE AND CHANGE ITS BEHAVIOR TO ALIGN WITH THE ERRONEOUS AND UNSAFE PRACTICES STATED HEREIN AND THE REST OF THEM - THOSE THAT TRULY KNOW BETTER - WILL FALL BACK TO WHAT WORKS - THE TRIED-AND-TRUE AND TRUSTED - BASIC WILDLAND FIREFIGHTING RULES.


My comments to @B Massaro: "Dude. I did organize my thoughts into a few statements based on the comments of the alleged “experts.”Yes indeed. They were in a safe in the black. And they could have – and should have stayed put there and / or hiked the black down into Yarnell. They knew the fire was in front of them because they had the best view of the fire besides Air Attack and all other aircraft. This was basically their home turf, so they should have been aware of how fast fire can move in high winds. And this is where Watch Out No. 4 seems to apply because they made decisions as if this was their first brush fire. Their leader(s) made the fatal decision to go down slope into that heavy fuel, etc., etc., etc. at the worst possible time. Yes indeed. They had to have known that.They had to know the fire behavior possibilities because they were on the Doce Fire only a week or so before. They had to know that potential was there. They obviously failed to do the math. Following the “Prescott Way” and comments made by PFD Wildland Battalion Chief Willis, regarding structures in his July 2013 GMHS Deployment Site News Conference videos ( https://youtu.be/J1lBgicPq5A ) and ( https://youtu.be/YDQRLXZV1Ro ). They certainly seemed intent on doing “something” which is one of the Hazardous Attitudes listed in the IRPG. You did hear correctly that the Helms family stuck it out there inside their ranch house. I commend them for staying in place. It was certainly less than “Bomb Proof” as some claimed, but definitely outside the stupidity zone. ( A = Gary Cordes, SPGS1 at the Yarnell Hill Fire… talking to ADOSH investigators… A: It’s a very large uh, 20 to 30 acre open site uh, that was real cleaned out and it was pretty – it was bomb proof. " “I've seen dozens a videos on this and everyone is making excuses but unless people say what needs to be said the young people getting into it are going to make the same bad decisions.” I agree with you here because otherwise, we are learning ”incomplete” lessons and similar tragic events will occur. There are other ways “the only way you get 19 people to die is when 18 listens to one when somebody should have spoken up and said hey the fires in front of us we shouldn't be going down slope through that fuel knowing that there could be wind issues.” Exactly, and you are describing Groupthink, once again one of the Hazardous Attitudes listed in the IRPG. This is what I believe made them all leave the black like a bunch of sheep. So then, I agree with you in principle here Lessons.1. evacuate people earlier you can never evacuate too early but you sure the hell can evacuate a minute too late which is what most idiot homeowners will do. Okay … however, all the Yarnell citizens successfully escaped the fire on June 30, 2013. It was the months and years afterwards that they died (and continue to die) in excessive numbers from various cancers due to the thousands of gallons of aerial retardant dropped indiscriminately for days! 2. don't be afraid to speak up the leadership if you think they are making a bad decision putting your crew in Jeopardy which clearly happened.I agree with you and many of the GMHS did, in fact, do just that, especially Steed. However, he finally succumbed to Marsh’s pressure and led them all to their deaths.Regarding Watch Outs 4, 11,12 , 13, 15, 7 – I agree with all of these except Number 13 because when they were traveling along their perverted Escape Route, they were not building fireline on a hillside where rolling material can ignite fuel below them. (all emphasis added)


Restating, as viewed above in Figure 10. there are high-level criticisms by some high-level alleged WF “leaders,” by way of the Wildland Fire LLC (WFLLC), that the WF Rules “cannot work... not going to keep us safe” and we need to rely on “luck decision conversations.”[15]


 

Inexplicably, yet fitting squarely with the pattern of cover-up, lies, and whitewash, the National Interagency Fire Center (NIFC) urged YH Fire investigators to withhold some findings from the public, and to avoid analyzing whether crews violated fundamental fire-line rules in the AZ Republic. (emphasis added) (NPR).[16] Fortunately, this is also addressed in an Academia.edu paper in other than a National Propoganda Radio article. Dr. Gaunther's paper is titled: "July 18, 2014 USFS Response and History Report" by Dan Guenthner PhD (ABD) MS (Fire Service Organization, Management, Leadership, and Ethics (FSOMLE) dated July 29, 2014. USFS Response and History Report. Dr. Guenthner refers to a "U.S. Wildland Fire Service" likely innocently in a general sense because there is no such Agency or Service. He goes on to point out (accurately at the time of his paper): "Wildfire fatalities automatically lead to detailed investigations, typically using guidelines from the NIFC. The goal is to find out what went wrong and what lessons may be learned to avoid similar tragedies. There is [sic] at least six decades of lessons learned and we keeping repeating the mistakes over and over. Just like they recycle the recommendations over and over, nothing appears to change. Another big issue that flies in the face as what some would characterize as unethical behavior and/or leadership is the NIFC's current "Interagency Serious Accident Guide" which instructs those who conduct fatality inquiries to address causes of the tragedy only in a report that would be confidential. The guide tells investigators to avoid analyzing whether basic fire-safety protocols were violated and to destroy draft documents [emphasis added] after the inquiry is done. Similar instructions have appeared in previous versions of the guide. (p. 18) (all emphasis added except the bracketed [emphasis added' is in the original document) The link to the original Interagency Serious Accident Guide was non-existent even using the Internet Archive Way Back Machine.


Dr. Guenthner specifically addresses the YH Fire on pp. 19-21. "Yarnell Hill Fire - This is the worst loss of life in 80 years! I have read and re-read the reports and investigation and it SCREAMSfor organizational change that deals with the organizational safety culture and safety related behaviors, among other issues. I disagree with Mr. Kris Bruington, superintendent of the Lone Peak Hotshots in Utah when he stated, "...other than reinforcing the need to focus on the time-tested basics of lookouts, communication, safety zones, escape route and every crew member's right to speak up about safety concerns, there's little to learn." Not once did he discuss management issues here and focuses solely on the crew's responsibilities. There is a tremendous amount to learn from this incident. Clearly the land management agencies are running scared of lawsuits; and they should be because they have done nothing that has effectively improved the injury and death rates over the history of wildland firefighting. (emphasis added) The GMHS DZ photo below is in his original article.


"Not uncommon in these incidents, as we have seen in the past, the Arizona Forestry Division does not find fault with their decisions. They are deflecting all responsibility onto the Hotshots, the incompetent dead. We all know differently though. The Arizona Department of Occupational Safety and Health report blames managers for failing to see that the town of Yarnell was essentially doomed and should have pulled all crews out hours before the Hotshots deaths. What risk management decisions were made that didn't pull personnel off the fireline. In reviewing the State of Arizona Forestry Service Yarnell Hill Fire report (2013) there were only cursory mentions in several areas of the report about organizational culture and safety culture was totally ignored (Yarnell Hill Fire, 2013, p.59). This internal report and analysis followed the trend of all the other reviews going back to the South Canyon Fire (1994). This two decade period is devoid of in depth review of management and organizational culture change or the changing of the organizational safety culture within the U.S. Wildland Fire Service. Weick was referenced in the report to discuss "sensemaking" a term he popularized (Yarnell Hill Fire, 2013, p. 46). The stated intent of the Yarnell Hill Fire, (2013) report stated "...how the wildland fire community can improve at the individual, team, and organizational levels."(p. 45). Based on these comments from the Yarnell Fire Report it would appear nothing has been learned or implemented to change organizational safety culture or organizational culture since the Tri-Data Corporation (1996-1998) study indicating the USFS needed to work on their safety culture and organizational culture. According to Thackaberry (2004) the Tri-Data Corporation (1996-1998) self-study of the USFS after the South Canyon 1994 fire "...management feedback influenced [emphasis added] the development of the reports." (p.239). Since the Thirtymile Fire (2001) the general sense of the public was dissatisfied with Safety Awareness Study as used in every major fire and the 1996-1998 Tri-Data self study and McDonald and Shadow in 2003-2004 study. We see this in the most recent incident report on the Yarnell fire (Yarnell Hill Fire, 2013). Many questions still linger within the U.S. Wildland Fire Service at numerous levels. One of the most perplexing issues that is seen is the "recycling" of the same safety recommendations. We see this in the Yarnell Fire (Yarnell Hill Fire, 2013). It has become clear self-studies do not answer the questions or make the correct changes. They especially do not address organizational cultural change or organization safety as needed since 1990's and possibly earlier than this decade. This makes a strong case to have external investigations the need to study the root cause - e.g. organizational safety culture and organizational cultural change. In the case of regulatory oversight in the Yarnell Fire (Yarnell Hill Fire, 2013), the Arizona Department of Occupational Safety and Health (AZDOSH) conducted an investigation and came away with a totally different view based on additional facts. A number of initial issues came out, mainly the federal agencies refusing to cooperate and not provide personnel to be interviewed. This should not have been totally unexpected since over the last three decades, and especiallysince the Thirtymile Fire (2001) documents released had been heavily redacted by the federal agencies when releasing to the public. Mistrust becomes a big issue in these incidents and a question of the organizational culture is called into being part of this issue. Secondly, the Wildland Fire (2013) report provides an excellent review of this issue and is cause for concern if organizational safety is even engrained into the organizational culture at all. This provides additional data why the research of organizational culture and organizational safety climate, from an independent standpoint is so critical to study. The inspection narrative would indicate a way the U.S. Wildland Fire Service does not want to be studied in these areas, as the outcomes may not be favorable. An example of poor safety and risk management came on June 30, 2013 at 1150 hours and deteriorated the rest of the day until the 19 Granite Mountain Hotshots were entrapped and burned over killing them.The recommendations from the Yarnell Hill Fire (2013) report only addressed one issue that is on the very fringe of organizational safety and organizational change was to work with "human factors" experts (p.44). Most [of] that study [is] the need for organizational culture and safety in the fire service find very quickly it is necessary and a requirement to improve the safety culture. (Cooper, 2000, Crossman, 2008, Desmond, 2011, Kupietz, 2011, Pessemier, 2010, Pessemier & England, 2012). In the U.S. Wildland Fire Service we have mostly, if not exclusively, seen organizational self-study which can be discursive openings for organizational discourse (Thackaberry, 2004).( all emphasis added) (pp. 19-21)


Restating, as viewed above in Figure 10. there are high-level criticisms by some alleged WF “leaders,” by way of the Wildland Fire LLC (WFLLC), that the WF Rules “cannot work... not going to keep us safe” and we need to rely on “luck decision conversations.”[15]

 

The authors and most WFs whole-heartedly agree on the validity of the WF Rules, disregarding “luck decisions.” Abiding by defensive WF Rules and human factors is missing in most fatal wildfire investigation reports.[14]


When asked by ADOSH investigators, alleged GMHS “lookout” McDonough, just moments after admitting that it was ‘policy’ for the GMHS to always ‘risk a lot to save a lot’ in Wildland Firefighting (i.e. Fight fire aggressively, having provided for safety first, the 10 & 18, LCES, etc.) - he said: “It’s –it’s hillbilly. It’s what it is.... It’s old. It’s, uh, no offense to whoever came up with that, um, I mean no disrespect to anybody, but, I mean, it is the way they fight wildland fires today...is, I mean...Oh it’s...We’re smart. We’re a lot smarter.”[17] Yeah right, they were so smart, that with this cavalier safety attitude, the entire Crew, except one, was killed! In his book supposedly defending his Brothers’ actions, he confirms this, yet he never cited any of the WF safety rules. A third year rookie GMHS had to be coached on this because there is no way he came up with that on his own. Moreover, it helps to understand the undergirding safety attitude and actions of the GMHS leading up to June 30, 2013.


Consider now (below) several of the human factors discussed and inferred from the text above with several more that relate to this important, yet neglected subject area.

 

Prove all things; hold fast that which is good. Thessalonians 5:21 KJ V

 

UPDATES: Minor spelling, punctuation, and grammar corrections and edits throughout post, added many links to several of the sources, and added Figure 10.a. NIFC WFSTAR Fire Order video. (May 30, 2021 at 10:00 PM)



Proceed to Part 2 of 2 here - Why Were Vital Human Factors Influencing the June 30, 2013, YH Fire GMHS Fatalities Never Revealed?