Learning Review released for smokejumper fatality

A report called a “Learning Review” has been released for the Luke Sheehy fatality, the smokejumper who was killed by a falling limb while suppressing a wildfire on the Modoc National Forest in northeast California on June 10. In addition to the primary report an additional document with supporting information, including some mind-numbing charts, was released.

The objective as stated in the document was to “understand the rationale for the actions/decisions involved in the incident and then, if possible, to learn from them”.

Frequently at Wildfire Today we will write a summary and then our analysis of serious accident reports, but this particular document is very different from the traditional report. It adopts the new paradigm of leaving out conclusions and recommendations, a process that began to be etched into stone in August when the Serious Accident Investigation Guide was revised. This Learning Review claims that “conclusions can sometimes close the door on learning”. I would say on the other hand that they can more frequently open the door to an enhanced safety environment for firefighters. People can sometimes be hit by meteorites, but not often.

And like virtually every research paper, most of the recommendations are for additional studies, ensuring continued employment for academics and researchers.

Call me old school, but this document appears to be more useful for human behavior researchers than firefighters. How did we get to the point where language such as this is used repeatedly in a U.S. Forest Service funded official report about a wildland fire?

  • “Typical mission flow”
  • “Synthesis, analysis and sensemaking”
  • “Margin of maneuver”
  • “Sensemaking team”
  • “Single Loop vs. Double Loop Learning”
  • “Hoberman Sphere”
  • “Pressures and filters”
  • “Mind maps”
  • “Auditory signal”
  • “Signal detection”

The Learning Review does suggest that two additional products be prepared, one for “the field” and another for “the organization”. Maybe the field document, if produced, will be more useful for firefighters. And presumably the organization version will have conclusions and recommendations that will remain secret if the guidelines revised in August are followed.

I am not sure why the U.S. Forest Service paid the 22 people, plus multiple focus groups, to produce this study if they did not receive for their investment products usable by the field or the organization.

But I am old school when it comes to opportunities for learning lessons.

Author: Bill Gabbert

After working full time in wildland fire for 33 years, Bill Gabbert now writes about it from the Black Hills. Google+

12 thoughts on “Learning Review released for smokejumper fatality”

  1. I consider myself well read, educated and in tune with the English language, what do all these new terms mean?

    In my career I have investigated and written many types of reports including a number of reports on accidents or events with injuries and deaths. I tried to keep reports to the facts, clear concise and to the point using direct understandable language. These included probable incident causes and recommendations to prevent more accidents.

    This new type of report writing will put the target audience to sleep and fail to get the point across of why something happened.

    I’m old school also and without cause and conclusions these reports are not going to be much use to anyone. As Jack Webb on the old TV show Dragnet said, ” Just the facts please”.

  2. Well Mr Morgan and Bill

    One can only surmise a couple of things……….transparency in Govt…which we know very well how that is working and …..

    The so called “educated” writing these have some lawyers some where hovering.

    AND if something is being kept secret during all these SAITS……then the the NTSB and National Fire Administration should have some REAL oversight into this and all future events…….some how, as a pilot, I would not want any of the uneducated folks who have not flown or fixed aircraft in the aviation world (spell SAITS team members without commercial pilots or A&P certifications) EVEN to assess any more then there OWN lanes of disciplines. That is why the FAA and the NTSB ought to be the ONLY folks in those arenas…once again LMA’s only a party to those issues and NOT leads of any sort….

    These folks ought not consider themselves professionals in reading the minds of personnel in the accident world.

    If these clowns are conducting interviews on My and your taxpayin dime…….then NONE and I mean NONE of these SAIT’s, FLA’s and what not even become secret

    Full disclosure or nothing at all………the taxpayer deserves answers and if like in the civilian world……if a head is going to roll……then maybe it might need to

    How many Generals has O fired this week? Maybe some LMA heads need to be fired……a lot of the accidents have demonstrative qualities that go back a s far as Mann Gulch and the LMA has a repeats of similar accident issues that maybe the entire LMA fire program needs to be taken to the woodshed for a little, what we used to call, one on one or wall to wall counseling

    Oh wait…..it’s 2013. A new age..we can hurt somebody’s feelings

  3. I agree that I would like to see some conclusions and recommendations. Having said that this report does actually concede that some mistakes were made (unlike some other reports we all know), and tries to look deeper to see where these behaviors come from. Simply pointing out the mistakes and who made them has not worked. We need to be asking why more.

  4. Why?

    How about a culture that needs some serious addressing…..

    First and foremost……the moniker ….10’s and 18’s..”we don’t bend them and we don’t break them.” Seems like a challenge to the egotists somewhat like the macho attitude mentioned by the FAA in all their training.

    Simply writing SAIT’s to satisfy writing about mistakes and conceding there were, simply does not pass muster for a lot of accidents that are very similar.

    Some what like “pilot error.” It will always come down to that EVEN in the wildlandfire world. To say that WFF’s are superhuman in the SJ and HS world, is preposterous.

    All the accidents written about in the last Ten fire seasons had a number of factors that had some sort of mitigation written all over it

    ALLLl those upper level 280 through 620 types classes for”leaders” sure haven’t produced the leadership that even comes close to following into combat.

    Time for all that SAIT writing ability to TEACH and PRACTICE mitigation instead of writing about it afterwards to satisfy not assigning blame or pointing fingers.

    This field, like aviation, has dangers written all over it…..some how the last bunch of SAIT’s, FLA’s, and Lessons Learned need a lot more attention to them than just writing reams of paper and using bandwidth to state some of the very obvious!!!!

  5. Wow… that was painful to read. A lot of Masters and Phd thesis’ came out of that format. I quit reading it after the first couple of pages. Who comes up with this? Agreed… the facts please.

  6. I actually like the review. It states blatantly in the beginning of the document:

    Conclusions can sometimes close the door on learning, by suggesting that all information has been found and judgments can be made. Judgment is always biased from the perspective of the reader, with the assistance of hindsight. Instead, this Review allows vague and sometimes unresolved concepts to emerge, allowing tension to be created for the reader. This tension can inspire dialogue in the firefighting community and the organization, and encourages sensemaking around the presented concepts

    There is too much desire to simplify an investigation with “just give the facts so I can make a decision” mentality. This review takes us away from the assumption that we can look at the facts directly related to an accident and prevent it from happening again – or decide why it happened. There are some new concepts, specifically Margin of Maneuver, that will help FF understand the process that lead to the fatality.

    1. The wildland fire world doesn’t need final docuements with a bunch of bunk ” buzz words.” As a Supervisor of a 20 person HC; I need to use and understand this information as a teaching tool to those who actually are exposed to this risk on a daily basis. I don’t have the time to decifer all of these phrases and words. I stopped reading reading this docuement, because it became meaningless to me.

      1. The incident wasn’t complicated. Why it happened is. Answering your comment about needing information to relay to crewmembers (I myself supervise 10 and run 20 person crews): Maintain situational awareness.
        Beyond that, what more can be said based on the fatality report?
        But what additional information does that provide us for future use? Providing terminology to address ways to mitigate and understand our failures doesn’t necessarily create “bunk” terms. Unfamiliar, yes, but that is how things start.

  7. Producing a report with so much politically correct “psycho-babble” does a dis-service to those in the field that are exposed to similar risks, and had hopes that this review would help identify key factors to their efforts safer.

    1. What was PC about the report? “Psycho-babble”? “Crew Cohesion” probably fell into that category at some point in our vocabulary, but now is a staple, almost cliche, term in the fire safety world.

      How does it make us safer? Well, the crew started digging line around the tree onto the side with the limb load. Obviously this is not a good idea on a tree that is severely compromised. So, the easy answer is, don’t work below a hazard. The harder question is, and the one the review addresses, is WHY did this happen? Why do similar things happen over and over? How do we look at a larger, overall view of risk and mitigation but still accomplish what we need and are paid to do? Just because it’s not a simple, cut-and-dry response doesn’t mean it’s not valuable.

      It would be a simplified response to look at this incident, place blame, and think we learned anything. If I learn anything from near misses, accidents, and fatalities, it is how close I have to been to similar situations, but through luck, timing, or other factors that may or may not have been in my control, made it out unscathed. The Thirty Mile Fire incident was one of the seminal events that made me realize I could have been there and suffered through the same situation.

  8. This morning’s paper reported on the 4 Marines that were killed in an IED accident yesterday in California, and referenced an earlier training accident that killed 7 Marines in a Mortar explosion in Nevada. It said that the military Investigation “determined human error was to blame ,,,,,, a Marine did not follow correct procedures ,,,,,, and that the mortar team had not conducted appropriate preparatory training.”
    I was reminded of the old flick “A Few Good Men” with Jack Nicholson and Tom Cruise: lawyer Cruise is badgering witness Colonel Nicholson about how a Marine died, and Colonel Nicholson roared back “You can’t handle the truth.”
    Wonder what “Colonel Nicholson” would have to say about this Report and the Report on the Granite Mountain fatalities?

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