Preventing The Next
Tragedy Fire
A Leadership Challenge And Responsibility
1
The root causal factor in
entrapment fatality fires directly
relates to leadership at all levels
of the organization!
The next entrapment is entirely
preventable and totally unacceptable.
Does leadership have the will to change?
2
Purpose Of This Presentation
• Present the case that leadership is the key to creating an
organization that knows that things are done right, and
improves performance every year
• Present some early thinking on how to make the
transformation from an assuming to a learning organization
• Make some suggestions for the next steps
3
A Few Qualifiers
• We have a great fire management organization. Comments
and thoughts are only intended to make it even better
• When the word leadership is used, it refers to the work of
leaders from firefighter to chief
• The most important work of leadership is to translate intent
into action, and to set an organizational climate where
firefighters are consistently improving performance and
meeting expectations
4
The case for change.
Premise: If our organization was improving every
year, the probability of fatalities and serious
accidents would be low and getting lower every
year.
5
Current Expectations Referenced In
Chief’s letter 10/29/01
• We must take a proactive, inclusive approach in designing
work projects and activities, and in developing supporting
policies and procedures to ensure that our employees are
never in “harms way.”
• In the Forest Service, safety is more than just a word.
Safety is: “The Relentless Pursuit of Employee Protection”
• …… ensure zero tolerance for placing employees at
(unmitigated) risk ….
6
Current System Relies On
Assumptions
Current System
Accountability for:
Bad
Outcomes
Bad
Outcomes
Bad
Outcomes
Bad
Outcomes
Bad
Outcomes
National
Expectations
Regional
Expectations
Forest
Expectations
District
Expectations
Incident
Expectations
Feedback Control System:
Assume
expectations
are followed
Assume
expectations
are followed
Assume expectations are followed
Assume expectations are followed
Assume expectations are followed
Assume expectations are followed
Assume expectations are followed
Assume expectations are followed
Assume expectations are followed
Individual
Expectations
7
Desired System Relies On Knowing
Expectations Are Met
Accountability for:
Meeting
Expectations
Meeting
Expectations
Meeting
Expectations
Meeting
Expectations
Meeting
Expectations
Desired System
National
Expectations
Regional
Expectations
Forest
Expectations
District
Expectations
Incident
Expectations
Feedback Control System:
Monitor to ensure expectations are met
Monitor to ensure expectations are met
Monitor to ensure expectations are met
Monitor to ensure expectations are met
Monitor to ensure expectations are met
Monitor to ensure expectations are met
Individual
Expectations
8
Two Safety Cultures
An Assuming Culture
A Learning Culture
Communicate expectations
Communicate, demonstrate, and
model expectations
Assume that expectations will be Check to see that expectations
followed
are being followed, and hold
people accountable
When things go wrong, place the When things go wrong, learn,
blame, fix the problem, and move modify, and make sure it does not
on
happen again
Surprised by the unexpected
Ready for the unexpected
Accidents will happen
Learn how to prevent
9
Current Organizational Reality
• Three entrapment fatality fires over the last ten years have
killed 20 employees
• Many employees believe that fire management work is
hazardous by nature, and its just a matter of time before
another fatality occurs
• All entrapment fatalities to date have been preventable, and
share the same basic causal factors
• Leadership has started holding fire managers and line
officers accountable for bad outcomes instead of holding
them accountable to meet expectations all along
• Fire managers are uncertain about personal risk and
accountability when critical mistakes are made
10
Common Causal Factors for
Entrapment Fatality Fires
• South Canyon, Thirty Mile, and Cramer fatality fires had
two general causal factors in common:
– Inadequate organizational oversight
– Human error
11
Inadequate
Organizational Oversight
• Leadership failed to create an organizational climate where
expectations were routinely followed
• Organizational oversight failed to prevent, recognize, or
correct critical errors before entrapment
• All three of the units were experienced and recognized as
competent fire management organizations, and viewed
these incidents as routine
12
Human Error
• All of the last three entrapment fatality fires resulted
directly from Incident Commander decision errors, and
failures to follow established practices and procedures
• The errors were made by fire managers that were qualified
and experienced
• In all three of these tragedy fires incident personnel
considered the task at hand to be routine
13
Other Important Commonalities
• Thresholds of predisposing risk had been exceeded, and
leaders/managers/firefighters did not change strategy
• What had become routine strategy during low to moderate
risk incidents failed when the unexpected, high-risk fire
blowup occurred
14
Failure To Adjust Strategies As
Risk Increase Can Lead To
Tragedy
Death
Zone!
Extreme Risk Level
Risk
Level
High Risk
Zone!
Maximum Acceptable Risk Level
Incident Maximum
Potential Risk Profile
Risk Profile of
Implemented strategy
Time
15
Altering Strategies As Risk
Changes Contains Hazards
Death
Zone!
Extreme Risk Level
Risk
Level
High Risk
Zone!
Maximum Acceptable Risk Level
Incident Maximum
Potential Risk Profile
Risk Profile of
Implemented strategy
Time
16
Critical Hazards
• Even very experienced fire managers will periodically
make critical errors that, if uncorrected in high-risk
situations, can lead to entrapments and fatalities. This is a
hazard that must be anticipated and mitigated
• Organizational oversight should function as an absolutely
essential failsafe before and during an incident, and is the
primary responsibility of leadership at all levels. Failure of
oversight leaves firefighters exposed to human error in
complex and high-risk situations.
17
It’s Time To Change!
• “The definition of insanity is doing the same thing over
and over again, and expecting a different result.”
Albert Einstein
• The problem is not the people, policy, procedures, or
practices. Rather the problem is leadership at all levels has
not redeemed the responsibility to monitor and set a
climate that ensures employees will:
– Make the right decisions and follow expectations
– Alter strategy as risk changes
– Prevent or correct errors before they lead to tragedy
18
Desirable Future
An organization that:
– Focuses continually on improving performance to meet
expectations and, as a result, achieves increasingly
better outcomes
– Has a lower probability of a serious accident every year
– Holds individuals accountable for meeting
expectations, and, as long as they do, stands by them if
things go wrong
– Has a culture that acts and believes all accidents are
preventable
– Has systems in place that mitigate the hazard of human
error
19
Strategy For Creating The
Desirable Future:
Transform the organization by
developing and implementing quality
assurance systems.
20
What is success?
Success
=
Effective
Organization
+
Individual
Performance
+
Effective
Operations
Success
Effective Operations
Individual Performance
Effective Organization
Success is completing operations effectively, and
having a low probability of serious accidents or
fatalities that lowers every year as the organization
develops!
21
Quality Assurance Systems
Success
=
Effective
Organization
+
Individual
Performance
+
Effective
Operations
Quality Assurance Systems In A Learning Culture Context
Relentless pursuit of quality will lead Fire and
Aviation Management to become a learning
organization!
22
Fire & Aviation Management Learning Organization:
All parts of the system develop and learn through continuous
improvement feedback loops.
Evaluate & Learn
Improve
Goal
Feedback
Loop
Evaluate & Learn
Feedback
Loop
Goal
Policies, Practices,
& Procedures
Organization
Improve
Improve
Operations
Individuals
Goal
Feedback
Loop
Evaluate & Learn
Feedback
Loop
Goal
Improve
Evaluate & Learn
23
Ensuring An Effective Organization
• Effective leadership
• Well stated and clear
objectives (Commanders
Intent)
• Commonly held values &
principles
• Standard operating
procedures and effective
training
• Bias for action
• Ability to manage the
unexpected
• Upper level monitoring
and internal reporting of
hazards
• Feedback control system
• Accountable
• Site certification for
wildland and prescribed
fire operations
24
Effective Organization
Feedback Control Loop
Effective
Organization
Site audit &
certification &
de-certification
After action
review and
action plans to
improve
Line Officer
Incident
Performance
Review
Getting &
keeping
effective people
Training
Feedback Control Loop
Incident
Simulations
Experience
with incidents
Organizing for
Effectiveness
Readiness Reviews &
Leadership decision
simulations
25
Site Audit & Certification
• Primary aim is to certify line officer units at all levels for
wildland and prescribed fire operations
• Each line officer (National, Regional, Forest, District)
would clearly understand expectations for fire management
performance and safety, and would periodically receive an
audit to certify that systems are in place to ensure they are
being met
• Audit results would determine if a unit was certified, under
special monitoring status, or decertified
26
How do we ensure
individual performance?
An effective individual must:
– Have shared values and objectives
– Receive effective growth-based education and training
– Have the proper qualifications and experience for the tasks
assigned
– Meet currency standards
– Have the opportunity to practice between incidents
– Receive effective individual feedback, and a comprehensive
development plan
– Be evaluated and certified to meet the expectations management
has of his/her performance
27
Individual Performance
Feedback Control Loop
Effective
Individual
Training
Audit &
Certification &
De-Certification
Feedback Control Loop
Performance
Improvement
Plan
Incident
Experience
Simulation
Experience
Performance
Evaluation
28
How do we ensure
effective operations?
• By ensuring the ten standard orders are followed
• By ensuring the eighteen situations are mitigated
• By ensuring operational strategy and tactics shift as risk
changes
• By implementing an expert system to assist in risk
assessment and monitoring
• By performing real time, on-site monitoring
• By developing and implementing continuous improvement
plans
29
Safe Operations
Feedback Control Loop
Evaluation
Safely
Completed
Operation
Adjust
Tactics as
Risk
Changes
After Action
Plan For
Improvement
Effective
Organization
Effective
Individuals
Feedback Control Loop
Ignition
Detection
Fire Operations Decision
Support System
Size Up
Monitor
Operations
Response
Strategy
30
Fire Operations
Decision Support System
• Utilizes rule-based expert system technology to monitor
and advise line officers and incident commanders during
wildland and prescribed fire operations
• Aim is to improve decision-making and ensure safe, costeffective operations
31
Fire Operations
Decision Support System
• System Inputs
– Forest Fire Plan
– Weather – current &
predicted
– Fuels
– Topography
– Fire behavior – current &
predicted
– Local Situation, Staffing
and expected resources
– Predisposing thresholds of
fire risk
• System Function
– Maintained by “air traffic
controllers (collision avoidance
system i.e. entrapment
avoidance system )” – IC relay
info to dispatch
– Real time risk assessment &
forecast
– Suggested strategies based on
forest fire plan and real time
conditions
– Map/name of potential
incidents requiring intense
monitoring due to current
extreme risk OR predicted risk
32
Decision Support Concept
Weather Factors
Current & Predicted
Operations
Red
Monitoring &
Intervention
Protocol 3
Operations
Yellow
Monitoring &
Intervention
Protocol 2
Operations
Normal
Monitoring &
Intervention
Protocol
33 1
Fire Behavior
Factors – Current &
Predicted
Decision
Support
System
Risk Assessment
Organizational
Factors
Predisposing
Thresholds By Fire
Regime & Fuel
Model
The Decision Path Is Critical To
Safety AND Cost Containment!
Detection
Dispatch
Extended Initial Attack
Size Up
Type II Incident
Initial Attack
Transition
Transition
Controlled
Type I Incident
Transition
Mega-Fire
Transition
Incident Decision Path
Fire Operations Decision Support System
Real Time Risk Assessments
Automated WFSA Support Information
Mega Fire Model and Cost Containment Strategies
Flags Incidents That Are Classified As Extreme Risk
34
Fire Operations
Decision Support System
• Consider implementing this system as a module of FPA
• System will be used to help manage risk in wildland and
prescribed fire operations
• System will be used to help in cost containment and
managing mega-fires
• System information will be used for after action reviews at
all scales
35
Strategies For Success
Implement feedback control mechanisms for ensuring
success.
– Short Term: Implementing Cramer ARB action plan
will serve to create a feedback control loop for ensuring
effective Type III ICs
– Intermediate Term: Implementing a certification system
for line officer units will serve to ensure safe, effective
organizations
– Long Term: Implementing a fire decision support
system will serve to ensure safe, effective operations
36
Assumptions Lead To Tragedy
About 2% of the time routine practice is not enough to keep
firefighters out of extreme danger. About 1% of the time that
firefighters are in extreme danger, luck runs out and leads to
death!
37
To Prevent Tragedy
We must replace assumptions with monitoring and
improvement to stop that last 2% of critical errors
from occurring.
38
Hazard Defense System
Hazards
L
E
A
D
E
R
S
H
I
P
P
O
L
/
P
R
A
/
P
R
O
T
R
A
I
N
I
N
G
M
O
N
I
T
O
R
I
N
G
I
P
R
O
V
E
M
E
N
T
Potential
Losses
A risk management system that continually improves in
performance is an impenetrable containment for hazards.
39
Discussion
No leadership action or inaction is worth a life
lost.
What is leadership going to do to prevent the next
tragedy fire?
40