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


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


The authors - obviously being too clever by half - miscalcualted, mismeasured, mistakenly underestimated the halfway mark on Part 1 of 2 - Why Were Vital Human Factors Influencing the June 30, 2013, YH Fire GMHS Fatalities Never Revealed?


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


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


The authors intentionally restate the following section here to reconsider the bulk of the Human Factors implied within, and inferred from, the text of the AHFE paper. And, of course, lest we forget, like the SAIT did - oh wait - their's was intentionally masterminded to square with the "we will never know" ruse for the Kool-Aid Drinkers, Sheeple, and other gullible, (un)intentionally naïve non-thinkers. Gotta love those career bureaucrat, Team Players, and the squishy Go-Along-To-Get-Along, obsequeous syncophant crowd. How are all you Snowflakes doing out there?


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


All WFs [and municipal and structural FFs enaged in wildland fire] 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. basically “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)

G.1. Willingness to Properly Refuse Risk and former Turn Down Protocol.


It is largely agreed upon that wildland firefighting is a quasi-military venture; one is to obey orders unless they are unsafe, illegal, unethical, or immoral.[1, 2] It is located in the IRPG - ironically on page 19. [15] Confidently, it is safe to say that all WFs and FFs (notably supervisors) will be placed in these vexing situations often during their careers. Most of you reading this post will relate because you've been there at least once, right? And be assured that most of you WFs and FFs actually have been sent to "Division Siberia" (somewhere cold and mopped up) for failing to accept an unsafe assignment. Most importantly - in every instance - these supervisors must satisfy their critical supervisory duties to ensure their respective individual and shared safety and welfare - no matter what! So then, why did the GMHS leaders fail to heed this solemn supervisory duty to protect their men from unecessary risk and eventual harm on June 30th?


G.1.1. Ostensible Former Marine Corps and Military Quasi-ingrained Influence to Follow Orders


On June 30, ... the [three GMHS Marines] ... had a mission to accomplish [to] ... protect the community of Yarnell —and just like their time in the Corps, they were willing to lay down their lives to achieve that goal.” (emphasis added) Marine Veterans Among 19 Firefighters Killed. Miltary.com (online) Cpl. Chelsea Anderson. (Jul 24, 2013)


... Every [GMHS] knew that they were gonna protect ... Yarnell. And if they laid down their life, it’s just like the Marines, they knew what they had to do and there couldn’t be any more honorable way to die than the way they died.” (emphasis added) PFD Wildland Division BC

Marine Vet Killed Fighting Wildfire. Military.com (online) Posted by Member 26835147 (August 2, 2013)


The Morality of Obeying Stupid Orders by John Reed (Viet Nam Tean Leader) (October 6, 2015) with excerpts from his video In a Time of War (2008) by Bill Murphy, Jr. "There is no need to question every order, just orders that may get you or those you supervise killed or injured engaging in an activity that either should not be done at all or that should be done more intelligently." John T. Reed's blog about military matters.


The authors and many other WFs and FFs - both current or former military and non-military - feel that there was at least some influence from above on them to "follow orders." And the authors and many others feel that was the case on June 30, 2013, when Acting Supt. Steed reluctuntly yet dutifully, as a former Marine, followed orders and led his men off the Weavers and "the black" into oblivion. Be sure to read well the former Doce Fire interactions (below) and Steed's most prescient comment. Risk Management and Systems Analyst Gordon Graham says "What's predictable is preventable." (emphasis added) FireRescue1 December 11, 2019.


Blessed is the man that walketh not in the counsel of the ungodly, nor standeth in the way of sinners, nor sitteth in the seat of the scornful. But his delight is in the law of the Lord; and in his law doth he meditate day and night.And he shall be like a tree planted by the rivers of water, that bringeth forth his fruit in his season; his leaf also shall not wither; and whatsoever he doeth shall prosper.The ungodly are not so: but are like the chaff which the wind driveth away. Therefore the ungodly shall not stand in the judgment, nor sinners in the congregation of the righteous. For the Lord knoweth the way of the righteous: but the way of the ungodly shall perish. Psalm 1: 1-6 (KJV)


G.1.2. Risk Assessment, Gut Feelings, Intuition


According to David Clancy, Human Safety Systems (AU): "At some point, all firefighters will be required to make judgment calls on risk. The trigger for this risk decision may be just a feeling that they have. This “feel” is often difficult to quantify but is based on knowledge and skills gained over time for making sense of the environment. Gut feelings, intuition, and professional judgment play a strong role in the overall risk management process when fighting wildfire. The importance of judgment calls in risk management links back to the overarching concept that risk is subjective and contextually driven (Adams 1995, Reason 1997, Clancy 2005, Sadler et al. 2007). The decision-making process is continuous so there are ongoing opportunities to decide what is or is not acceptable.(emphasis added)


There is intentional simplification and unintentional simplification. If you have intuitive impressions, are you backing them with facts? Fact-check your intuitive feelings. Intentional simplification may have ulterior motives. For example, your supervisor may want to increase productivity at the expense of safety.


This occurred several times for the GMHS on the June 30, 2013, Yarnell Fire, both before they were engaged on the Weaver Mountains and certainly as Steed was arguing with Marsh on the GMHS Crew Net channel during their strained "discussing our options" radio conversation while they were safely "in the black." Recall from Part 1, PFD Willis at the July 2013 GMHS Deployment Site News Conference video:"no firefighter is satisfied sitting in the black, in a SZ watching the fire progress below them." More of "The Prescott Way"?


On June 30, 2013, the GMHS was still assigned to the Doce Fire and a few other misc. ABC lightning fires on the PNF when they were ordered for the Yarnell Hill Fire. This occurred even though they were told by Marsh that they were "unavailable" for reassignment with many staying up way too late for what was to befall them. While enroute to the YH Fire, Steed met with two USFS employees he had worked with on the Doce Fire the week or so prior. They casually asked Steed how things were going. And Steed matter-of-factly replied "The way things are going Marsh is gonna get us all killed." This conversation was heard by both of these USFS employees during the GMHS travel to the YH Fire.


And on several occasions, several years after the fire this conversation was recounted several times, with the authors, and on one occasion, in the presence of a retired USFS wildland firefighter, so it's considered credible eye witness testimony to these former Doce Fire USFS employees; and credible Hearsay Evidence to the rest of us.


G.1.3 AZ Revised Evidence 803


The following are not excluded by the rule against hearsay, regardless of whether the declarant is available as a witness:


(1) Present Sense Impression. A statement describing or explaining an event or condition, made while or immediately after the declarant perceived it. (2) Excited Utterance. A statement relating to a startling event or condition, made while the declarant was under the stress of excitement that it caused. (3) Then-Existing Mental, Emotional, or Physical Condition. A statement of the declarant's then-existing state of mind (such as motive, intent, or plan) or emotional, sensory, or physical condition (such as mental feeling, pain, or bodily health), but not including a statement of memory or belief to prove the fact remembered or believed unless it relates to the validity or terms of the declarant's will. (emphasis added) Source: CaseText.com


Therefore, this is compelling evidence of the credibility of gut feelings and intuition addressed above. And even more so, it is chilling to think that Steed, in spite of this notion and arguing with Marsh over their discreet Crew Net frequency, about leaving their Safety Zone "in the black" somehow compelled him to lead his men downhill into steep chimneys and chutes choked with dense, volatile chaparral, into one of the possible firing operations raging upslope as seen in Part 1 of 2 in Figures 1, 2, and 3. above. It's disturbing and at the same time numbing and stunning.


G.2. Plan continuation bias.


A very potent, unconscious cognitive penchant, impeded the GMHS’ ability to know they needed to change their course of action. Avalanche fatality scholars note that people generally have a strong bias for sticking with what they have now and let their minds default to what is given or what has already been decided. They rely on stay-the-course impulses all the time, often with deceptively satisfactory results.[18] According to a Wildland Fire Safety Training Refresher (WFSTAR) poster, it was ‘52 minutes from the blowup to the burn over,’ [4, 19] (Figure 12. directly below); yet it appears that the GMHS failed to notice and safely respond to obvious deteriorating fire weather and increasing adverse fire behavior and subtle to obvious human factors cues indicating that conditions were exponentially shifting during that time period. Instead, they were “discussing our options” about whether to stay or re-engage. And in a word - the totality of it all was virtually screaming to them to ‘stay put and stay in the black.


A mental blackout that appears to have completely impaired their intelligence assessments and decision making. Not only did they not see what they were seeing, their governing assumptions about their threats were just wrong, whether based on myth, fantasy, or plain wishful thinking.

(Kaplan 2017)


Figure 12. Blowup to Burnover poster. 52 minutes for Yarnell Hill Fire. Source: NWCG, WFSTAR


Wooden-headedness, the source of self-deception,” celebrated historian and author Barbara Tuchman wrote, is a factor that plays a remarkably large role in government. It consists in assessing a situation in terms of preconceived or fixed notions while ignoring or rejecting any contrary signs. It is acting according to wish while not allowing oneself to be deflected by the facts. (Kaplan 2017)


Why Dissent Matters: Because Some People See Things the Rest of Us Miss by William Kaplan (McGill-Queen’s University Press) ( https://www.thestar.com/news/insight/2017/05/21/how-israeli-intelligence-failures-led-to-a-devils-advocate-role.html ) How Israeli intelligence failures led to a ‘devil's advocate’ role. By Excerpt from Why Dissent Matters: Because Some People See Things the Rest of Us Miss by William Kaplan (McGill-Queen’s University Press) (Toronto Star) Sun., May 21, 2017. This type of self-inflicted blindness was commonly known to Israel and its leaders (battle-hardened rugged individualists until they decided to overcome that fault).


This is addressed further below in the G.16. Recommendations for Improvement to Thwart Groupthink - Israeli Defense Force (IDF) Tenth Man Rule section.


G.3. Steady Drift Into Failure Via Bad Decisions With Prior Good Outcomes.



Figure 12.1. Decisions and Outcomes Matrix Source: Schoeffler CAWRT PPT


The authors allege there is enough evidence of several instances of GMHS hazardous attitudes and actions support their drift into failure spanning from their first official Hot Shot status season in 2009 up until the YH Fire in 2013. These involved a repeated attitude of having to “prove ourselves” or “one-up” other HS Crews on fires, conspicuously due to their Municipal FD status.[9] One of the repeated statements made by Marsh was "we're GMHS and we think we can pull it off." For example, on the 2012 Holloway Fire in NV, their Crew Carriers were saved by an Oregon-based Contract Engine Crew in this VIMEO video (Figure 13. below). [9] Based on acquired public records, this was the second of three times another Crew had to “save their Crew carriers; on the Holloway (2012), Sunflower (2011), and YH Fires (2013).[9] GMHS Brandon Bunch was sick and tired of the GMHS Supt. always acting like he had ‘something to prove.’ According to author Kyle Dickman, “[H]e felt that under Marsh’s command, the Hotshots were always having to prove themselves” (p.54).[20] Is it safe to infer that the GMHS normalized deviance again and again? Or was it more so with sneaky good outcomes? [1, 2, 4, 9]


When I left, Eric had something to prove,” says Marty. “He was going to make that crew better than any other out there.” Former PFD GM (Crew 7) Crew Boss Marty Cole from 2004-2005. 19: The True Story of the Yarnell Hill Fire. Kyle Dickman (September 17, 2013) Outside magazine (online) (https://www.outsideonline.com/1926426/19-true-story-yarnell-hill-fire#close )

Smoke Screen - Forest Service ignored information from hotshot leaders about Granite Mountain’s history of bad decisions - John Dougherty


"The Yarnell Hill fire investigation conducted by the U.S. Forest Service deliberately ignored information provided by a former hotshot superintendent that the leader of the Granite Mountain Hotshots had a documented history of making bad decisions in violation of basic wildfire safety rules, federal records and interviews reveal. (emphasis added)


"A second former hotshot superintendent also contacted the Forest Service investigation leader, Mike Dudley, and reported that his conversations with Yarnell Hill wildfire supervisors immediately after the fire pointed to human error by the crew's leaders as the only plausible explanation for what happen".(emphasis added)


Consider now two comments from the article above. Posted by: SOFR on 05/27/2016 at 5:13 AM - The truth is something the Forest Service has never wanted and never will. The truth is what gets people like these two guys blackballed for ever. The State knew they could count on the FS and there was no agency better to cover this mess up . They have lots of experience at it. Marsh wasn't the only one out there. There's still many more. Tragedy 19 men killed senselessly? YES, but the biggest tragedy is these corrupt agencies burying the truth. Where do they find these people?" (emphasis added)


Posted by: Mark Hostetler on 05/26/2016 at 9:09 AM - Thank you Dave Provencio and Fred Schoeffler for telling the truth. Experienced leadership and non-hero based decision making on a hotshot crew or any fire crew is what keeps young, relatively inexperienced, crewmembers alive. My son, who Dave knows so well, has been exposed the past 16 years to the most extreme wildland fires in history. He is now leading a hotshot crew and I fully believe he has remained alive and fire wise in part because at the age of 20 I guided him to join the Geronimo Hotshots rather than another hotshot crew. The sole reason I gave him was based on my own experience of working many seasons with the Geronimo superintendent at the time. I emphatically told him, "you are going with Geronimo", and that I completely trusted the experience and leadership of that superintendent, saying, "He will watch out for you and keep you alive." (emphasis added)

For it is not an enemy who reproaches me; Then I could bear it.

Nor is it one who hates me who has exalted himself against me;

Then I could hide from him. But it was you, a man my equal,

My companion and my acquaintance. Psalm 55:12-13


"Betrayal is probably the most devastating loss a person can experience. To be betrayed, the person must first experience trust in the betrayer. It is fairly impossible for you to be betrayed if you did not trust the individual in the first place. Therefore, the definition of betrayal involves the act of someone violating your trust in them". (emphasis added) Monica A. Frank PhD (Excel at Life)




Figure 13. Contract Engine Crew on Holloway Fire (2012) Subtitle: We saved GMHS Crew Buggies Source: Vimeo



Figure 13.1. Screenshot of Figure 13. video above. Source: Vimeo, John Dougherty, CAWRT PPT



Bad decisions with prior good outcomes. This was the second time that someone else "saved" the GMHS Crew Carriers. Helmet cam video reveals active fire behavior jumped fireline and threatening GMHS Crew Carriers without anyone there while a GMHS WF (Lookout?) can be seen in the upper to middle-left part of the screen (freeze-frame) running downhill along the abandoned fireline between (2:40-3:25).(all emphasis added throughout this IM post)


The author of this video posted on IM as Methods.Thisthread (below) is well worth reading. "Methods says at July 2, 2019 at 11:53 am ( https://www.investigativemedia.com/please-begin-chapter-xxviii-here/#comment-479691 )


"I am the person who recorded the 2012 Holloway Fire in Nevada when GMIH buggies were saved. They were located/working up the hill building handline and putting out spots with a helicopter. Marsh was acting DIV and managing other resources. After saving their buggies (what is caught on film), we were asked to bed down for the night (spike out) on the line and GM, as hotshots tend to do, went off and bedded down by themselves. They didn’t bed down in the green watered pasture with the other resources but instead in dry grass and had to wake up to fire out around themselves during the night."


Methods says July 2, 2019 at 11:55 am “That’s two incidents within a 24 hour period that I personally saw on the Holloway Fire in 2012.”


Methods says, “Thank you very much for that. All of this is extremely important!

Methods says


July 2, 2019 at 2:40 pm


"In my opinion, Hotshots don’t sleep or associate with other resources, even when spiking out. They are a self-contained resource that rarely needs any assistance from other resources so they stick to themselves. Plus, the watered green pasture had lots of cow pies so maybe they didn’t like the smell.


Woodsman says - July 2, 2019 at 5:44 pm - Thank you, Methods.


"Did Marsh work as a DIV on the same division as GM? Was your engine assigned to the same division?


"How did you hear about the fire creeping into GMs sleeping area? That’s really interesting. Appreciate it.

Reply


Methods says on July 3, 2019 at 12:03 pm ( https://www.investigativemedia.com/please-begin-chapter-xxviii-here/#comment-479750 )

"Yes, Marsh worked on the same division as GM. I was an ENGB assigned to the same DIV and was working with them during the first 3-4 days before an IMT showed up.

We slept on the other side of the creek from them and heard them wake up that night.

WantsToKnowTheTruth says on July 2, 2019 at 7:59 pm - Reply to Methods post on July 2, 2019 at 2:40 pm


*******


"Thank you for posting!


"One of the things we’ve been scratching out heads about here for some time now is that there appears to have been a THIRD ‘incident’ involving Granite Mountain on that same 2012 Holloway fire.


"Just before the start of their 2013 season ( which would become their last season ), one of GM’s Squad Bosses suddenly took another job and GM had to quickly fill that position. FOUR current GM came under consideration for that open ‘Squad Boss’ position and then went through a standard City of Prescott Human Resources ‘job interview’ process. "All the documents associated with those interviews are still sitting online at the following PUBLIC link via the WayBack Machine


( https://web.archive.org/web/20151031112325/http://www.prescottenews.com/pdfs/GMHS1.pdf )

"In those ‘job interviews’… ALL FOUR of the GM crew members talked about an ‘incident’ on the same 2012 Holloway Fire that involved suddenly having to RUN, and traverse drainages, and then ARRIVE at a Safety Zone and THEN still needing to ‘burn it out’, apparently to protect themselves AND their vehicles.


"ALL of the candidates told the job interviewers that the fact that they were able to “keep their heads” during this Holloway Fire incident should count towards them being considered for the open ‘Squad Boss’ position. Does that ‘ring any bells’ with you?

"The ‘incident’ at the 2012 Holloway fire that ALL of the GM Squad Boss candidates were mentioning does NOT sound like the same ‘incident’ were they simply ‘woke up’ and had to burn out around themselves.

"So we’ve been wondering if there were actually THREE ( separate ) ‘incidents’ involving Granite Mountain at this one single 2012 Holloway Fire.


Methods says on July 3, 2019 at 12:00 pm ( https://www.investigativemedia.com/please-begin-chapter-xxviii-here/#comment-479748 )

"IMO, it sounds similar to the event that I caught on the video. Multiple members were running down the slope to get to their buggies; fire crossed drainages; I believe the crew members that made it down to the buggies ended up firing off around them. They may have assumed that they parked in a safety zone but it was literally in the green in a “V” drainage. Just my guess, but I can definitely account for two “bad decisions, with good outcomes” just on the 2012 Holloway Fire in Nevada.

Reply - WantsToKnowTheTruth says - July 3, 2019 at 12:29 pm

"Thank you, Methods. Yes. I agree. Looking at your video again at the following link… ( http://vimeo.com/48411010 ) …there are a number of similarities between what you filmed and the ‘story’ that all 4 of the GM Squad Boss candidates were saying in their 2013 job interviews.

They all described it more like an event that involved the ENTIRE crew having to ‘make it to safety’ and then ‘burn out the Safety Zone’… but there’s no doubt that other details match what YOU filmed.


"Regarding your statement…


Multiple members were running down the slope to get to their buggies;”


"Again… yes. At least one ( the first? ) GM crew member to come ‘running down’ is clearly seen in YOUR video, on the left side of the frame, hauling ass down that ‘path’ and towards your location while you saved their vehicles.


"Based on how fast he was running… it looks like he would have reached your position right about the time you stopped filming. Do you, by chance, remember WHO that ‘first’ GM crew member you filmed running towards you was? Did he SAY anything when he reached your position? You know… like “Thank you”… or anything else?


*******.


"Regarding at least one of the ‘bad decision with a good outcome’ on GM’s part that you FILMED… I’m just curious about the circumstances there.


"Was that basically a fireline that ‘backed into’ that location ( since the wind was blowing AWAY from your position as you filmed )… or was it a ‘spot fire’ from something else that had been happening off-camera, out to the left?


"I’m trying to figure out how the hell that fire could have gotten that close to those $150,000 ( each ) vehicles without GM even frickin’ NOTICING. Method, In your opinion, what do you believe was the reasoning behind them not choosing a safer place to bed down? Thanks!

( https://www.investigativemedia.com/please-begin-chapter-xxviii-here/#comment-479748


( https://web.archive.org/web/20151031112325/http://www.prescottenews.com/pdfs/GMHS1.pdf )


.4. Consequences of Inattention as Causal Factor.


This is another one that most WFs and FFs will readily recognize. Credible research on what is referred to as ‘inattentional blindness’ (IB) reveals that when someone is otherwise engaged, at times - they fail to “see” obvious clear, fully visible, yet unexpected objects or events. IB also leads one to miss items that one needed to experience.[2] If an event meets their belief(s), they may be more likely to exhibit IB for a sudden, possible critical visual event.[2] The authors and other WFs and FFs believe in our hearts that at least two (Former Payson Hot Shot - avid student of fatality fires and Warneke - Marine Scout Sniper with intense leadership training) of the GMHS had to take notice of what was occurring, and saying something of importance about the increased fire behavior and the critical human factors error chain that needed breaking.[2]


This likely occurred as they discounted so many signs and - failing to leave a lookout at their Lunch Spot or notifying Air Attack-hiked downhill into the friendly fire, raging uphill fire behavior from the likely Sesame Street - Shrine firing operation. (Figures 1, 2, 3.)[21] According to the USFS HS Supt. Quisling that actually possessed the "AFUE transcripts three-ring binder" they clearly indicated that "around the 1600 time frame" Marsh had repeatedly "ordered air support every 5-minutes" ahead of GMHS, "in their egress." [4] This follows the SAIT-SAIR statement by Marsh to Air Attack John Burfiend after witnessing a Lead Plane make a dry run. (SAIT p. 27) "[ASM2], Division Alpha, That’s exactly what we’re looking for. That’s where we want the retardant.” ASM2 Burfiend was supposedly the only one that heard it and insured that it be placed in the SAIT-SAIR. (emphasis added)


G. 5. Lunch Spot - When time stands still


This strange, yet documented phenomenon occurred on several fatality fires. Notably, the (1994) South Canyon Fire (CO) when and where numerous WFs hung out while the fire continued to progress. The second one was the (2002) Thirty Mile Fire (WA) when they had properly disengaged while the fire behavior progressed and willingly jumped into vans to assist some Engine Crews building fireline. Although, Squad Boss Tom Craven (RiP) intuitively knew they were in deep trouble when they arrived at their destination when he stepped out of their van stating "We're f**ked!" And of course, the third and most infamous is the (2013) Yarnell Hill Fire (AZ) where they spent hours watching the weather and the fire behavior below, all from the best view of the entire YH Fire except for Air Attack ,and the two YHF eyewitness hikers, Tex Gilligan and Joy A. Collura.


For all of them, it was as if they were oblivious to what was occurring around them as if time had literally stood still (at least in their minds); and then they re-engaged their respective fires that they were totally unfamiliar with, and unknowingly also unprepared to engage them safely.


G.6. Confirmation bias, also optimism bias, you start to see things that confirm your belief. Our ingrained nature is to be optimistic. You want to find you are successful and see it working.


The individual will also search for information that confirms the decision and ignore information that proves them wrong, confirmation bias.


Self-justification blocks the ability to learn from one’s own mistakes. Self-justification causes a blind spot at finding one’s own errors or those made by one’s respected colleagues. Self-justification is the primary enemy of reliability. The authors allege that the GMHS engaged in a lot of this behavior.


In situation awareness when the situation changes the people must alter the task. In confirmation bias we look for information that confirms our conclusion. It is challenging to recognize that bias in ourselves.


G. 7. Reductionism and The Logic of Failure - Recognizing And Avoiding Error In Complex Situations - The actions that lead to failure appear logical at the time


"People may reduce their hypothesis for problem solving into one element to make it easier to manage complex situations. This leads to the belief that if they can only correct that element or a specific person then things will become right. The reductive nature of this method, reducing things to the need for only one intervention, also interferes with identification of those elements necessary for a change in the system. As a result, the organization has incomplete knowledge of the system’s structure. "We can acquire knowledge of structure by probing with actions and evaluating positive and negative feedback. Positive feedback occurs when a change in one element enhances the desired element. Negative feedback occurs when a change in one element diminishes the desired element. The system may cycle back and forth with negative feedback used to make mid-course corrections looking like error. Is it really error or failure if we do not reach the desired goal? Confusing intention, what we would like, with motivation, what drives us, interferes with the actions necessary for success and clarification of our goals."


"Is it easier to achieve reluctance to simplify in a group setting? We tend to make it a simple problem with a simple solution. How you shape and define the problem helps you understand the solution. But some times we have a solution in search for a problem. Simplifying the problem and the solution can be dangerous." (all emphasis added)


Dorner, Dietrich. The Logic of Failure: Recognizing and Avoiding Error in Complex Situations. New York: Metropolitan Books, 1996. ( http://www.tnellen.com/ted/tc/logic.html ) The Logic of Failure book summary. This is an excellent book if you're interested in this subject area.



G.8. Habituation is a gradual decrease of strength of risk sensitivity due to: Repeated exposure to stimuli, which creates a sense of familiarity. ... In this way, we can become complacent to risks that were previously being perceived as hazardous. The result of habituation is that the impact of the anxiety response weakens.


A lot of accidents happen in the domestic environment because we are too complacent. This usually happens to those who have many years of experience and in the meantime have lost their risk sensitivity. The fact that it still happens shows the strength of habituation. Habituation constantly challenges alertness and eventually tends to win. Science Direct Topics (accessed May 2021)


G.9. Tunnel Vision and Auditory Exclusion.