Response to the Yarnell Hill Fire “Swiss Cheese” article

On December 15 we wrote about the Yarnell Hill Fire and compared some of the issues identified on the fire to James T. Reason’s Swiss Cheese model of accident causation. Of the 19 issues (or “holes”), we mentioned that one of them was having only one aerial supervision platform, an Aerial Supervision Module (ASM), on a very complex fire at the time the 19 members of the Granite Mountain Hotshots were entrapped and killed.

In a response, a friend, Tony Duprey, kindly submitted his thoughts on the subject. Tony was qualified as an ASM and was an Air Tactical Group Supervisor (ATGS) and Branch Director on a Forest Service California Type One Incident Management Team for 7 years and continues to serve as an ATGS after his retirement. Below is his response to the article, and below that, a question from me and his answer.

We thank Tony for taking the time to compose this well-reasoned article.

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While I agree with your summation and the use of Dr. Reason’s “Swiss Cheese Model,” there are two slices that I believe COULD be misleading and I would like to attempt to clarify.

The first is the Aerial Supervision Module (ASM) role. The ASM program is an excellent program when utilized as originally envisioned and intended. (I will cover this in another article to you in the coming weeks). Suffice it to say, the ASM program has evolved quite a bit from its beginning with the Alaska Fire Service (AFS) and the Bureau of Land Management (BLM).

Today’s ASM program enhances and strengthens both the stand-alone LEAD and Air Attack or Air Tactical Group Supervisor (ATGS) programs and positions. That is worth repeating: Today’s ASM program enhances and strengthens both the stand-alone LEAD and ATGS programs. How does it do that? Through cross-training, crew cohesion, having a firefighter (Division Supervisor qualified ATGS) in the LEAD cockpit, and having ATGS’s gain experience as a part of low-level (below 500 feet AGL) operations – and the aircraft/cockpit management process. So we end up with stronger stand-alone ATGSs and stronger stand-alone Leads.

What does an Aerial Supervision Module consist of? On the federal side – a qualified Agency Lead Plane Pilot and a qualified Air Tactical Group Supervisor who have had one full fire season as stand-alone experience in their respective positions. The module of two people trains together and works together as a crew, following cockpit and crew resource management (CRM) principles.

When used as originally intended, the ASM fills the equivalent of the Strike Team Leader (STL) position in the Incident Command System (ICS) organization. So the LEAD or ASM fills one of the STL positions, with fixed-wing airtankers as resources in the “Strike Team,” and the Helicopter Coordinator (HLCO) fills the other STL position in the Aerial Branch. So the ATGS in the Aerial Branch is equivalent to the Division Supervisor or Structure Group, Firing Group or Dozer Group Supervisor in the ground branches of the ICS organization.  Keep in mind that the ICS was built to expand and contract, as needed, so an ATGS may or may not activate the STL positions of LEAD/ASM or HLCO based on need, availability and agency requirements.

Let’s take a look at a little history. On the Cramer Fire (July 2003), which had two heli-rappeller fatalities, there was a qualified stand-alone ATGS and a qualified stand-alone LEAD on scene prior to the fatalities. The stand-alone ATGS had to depart for fuel, leaving the stand-alone LEAD with the ATGS duties – as is approved agency protocol. When the fatalities happened the ATGS was gone for fuel, and the LEAD “had” the fire without the benefit of an ATGS in the cockpit. It does not take too much imagination to see how having a fellow crewmember that was a qualified ATGS/DIVS in the cockpit in this situation could help sort out a confusing situation.

It is important to stress here that while some agency lead plane pilots come up through the fire service ranks – smokejumpers, hotshots, engines – most do not. Most are pilots first – some military, some ex tanker pilots, some ex contract air attack pilots – and then are put through an abbreviated “fire training syllabus” of fire classes, with some pilots spending a brief time with a ground firefighting module.

So why did the ATGS on the Cramer not have a stand-alone “relief” ATGS? I don’t know, but there are a number of possible reasons; one was ordered but not available, one was ordered but was diverted, one was ordered and filled but had a mechanical issue, the ATGS forgot to order one – all possible reasons that happen all the time.

In the original Yarnell report, it was noted that the ATGS departed because of pilot daily flight hour limitations. As we know, FAA regulations state that a pilot can fly no more than 8 hours a day, be on duty no more than 14 hours a day, and have 10 hours’ off-duty rest prior to resuming on-duty status. Why was there no “relief” stand-alone ATGS? I do not know, but I would assume that because the stand-alone ATGS had come from another fire, there may have been none available, or there may have been one ordered that had not yet arrived at the incident. It is not covered in the reports I have seen.

On large or complex fires, Division Group Supervisors often utilize STLs to manage a segment or geographical area for them – to help minimize span of control, sheer size, or complexity issues on an incident. The Aerial Group is no different. As a stand-alone ATGS, I often utilize an ASM or a Lead to manage the section of line (airspace) where we are dropping retardant – and this is accepted agency practice. The ASM concept provides more flexibility and safety because of the qualified ATGS on board. I can also designate the ASM or HLCO (with pilot and agency HLCO on board) to manage an Incident within an Incident (IWI) until the situation stabilizes.

ASMs also can and do function as a pinch hitter in the ATGS position, if the stand-alone ATGS has to “depart suddenly” – as it’s worded in the Yarnell report. Is it the best idea? Maybe not in all situations, but sometimes on an incident one has no choice. In a perfect world, all needed organizational resources would be immediately available for use.

The second “slice” would be the supervision of the ground forces and agency/incident organization. I agree with how you have put it all together, but do have a concern that, while organizational failures DO need to be looked at and dealt with, we need to remember where the buck stops.

As a longtime hotshot, no matter how confusing an incident situation was or how dysfunctional the organization and communications were, I knew there was one person on the crew who had the final say. The crew boss. There are many times in our past experiences on a hotshot crew that we may or may not have had the perfect situational awareness of what was happening on the fire. Who did we depend on to keep us safe? The crew boss or superintendent.

In talking with my current hotshot superintendent friends, they are adamant that the relatively new “turn down protocols” for unsafe or perceived unsafe assignments have given them the latitude to be more proactive in reassessing fire assignments and in communicating the turn down reasons and better ideas to the incident management on the incident.

On initial attack, extended attack and dynamic, rapidly changing wildland fires, we will continue to encounter the fog of war, “confusing issues” and incomplete ICS organizations. It is the nature of wildland fire and fire organizations.

This is the reason we train, why we have agency Standard Operating Procedures, and why we teach tactical decision making prior to and at the Crew Boss level … because that is where the final “rubber meets the road” decision making takes place.

Again, organizational failures do need to be looked at as you have done. We also need to know where the buck stops in entrapment avoidance.

Keep up the great work, Bill, and thanks for letting me voice my opinion.

Tony Duprey

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Note from Bill: After receiving the above, we asked Tony this: “You seem to believe that it is always best to have an ASM, rather than separate LEAD and ATGS. Do you think it is ever desirable to separate them out?” He replied:

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Maybe I can clarify… There is no such thing as ASM vs ATGS in my opinion…The BEST aerial organization on an incident is to have a stand alone ATGS in the “Group Supervisor” role, access to either an ASM or Lead in the Airtanker coordinator / Strike team role and access to a helicopter coordinator to fill HLCO Strike Team leader position. The best case scenario would also have relief for each position on hand and available. Unfortunately  that does not always happen as there are shortages in all aerial supervision positions.

So in the Airtanker strike team leader position, I would prefer an ASM over a Stand alone Lead for the simple reason that it gives me more options as an ATGS, and I feel it is a much safer operation both for the ground folks and the air folks..

So Stand alone ATGS and an ASM in the tanker coordinator position is the best case scenario in my opinion.

Author: Bill Gabbert

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

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2 thoughts on “Response to the Yarnell Hill Fire “Swiss Cheese” article”

  1. It is a sad day when an entire crew can ignore the very basic 10 standard fire orders and the 18 situations that shout watch out.
    I have personally ignored those basic
    rules.
    The outcome of those mistakes, can not be described!

  2. I will agree with Tony, in principle.

    But being a LEAD and ASM together in one operation…..wellll…….. we can see how that will work out in future. Crew cohesion, esprit de corps, training together, working together, living in close quarters together…………well there is ALOT of that heard that in the military….that stuff hotshots borrowed from them…..while we in the military have had ours issues…….not a stick of timber nor scrub, sagebrush, ceoanthus, greasewood, or other fire prone species is worth alllllllll the heart ache to PROVE a point for an ATGS platform…….we all get the necessity of the mission……keep defending that….it ain’t bringing any body back

    The publication Scratchline approx 2008 mentioned a. Couple of basic problems in the ATGS program…namely…..some folks don’t like flying or in cramped quarters or those UTF rates for ATGS or ATGS (T)

    Now ….I understand some of the necessity of DIVS being in SOME of the roles. But the fire biz has some how locked out a number of individuals NOT in PFT (career status).

    Surely there are some unemployed Airtanker pilots , copilot or even up n n budding Airtanker types could get the feel of this work…you know….AD types.

    But the real problem being addressed here is the issues of the 10’s and 18’s that no amount of AC690 or King Air C90/100/ 200 series flying time is going to correct anytime soon.

    The real need to identify and correct is the ground CRM skills and position borrowing and hiding of facts that apparently needs ferreting out.

    To me, as a former engine slug and helislacker………..there is a SOLID need for a lot more educatin that needs to be done and obviously whether it is a city, state, or Federal hotshot crews. Obviously the 10’s and 18’s need more pounding into the cranium and really…….this thing needed to jumped on earlier in the IA process……maybe AFS likes the USFS method….screw IA, let it get big..then we will work it..

    This whole thing could have been prevented….but I am Monday morning quarterbacking here ….6 months later……

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