What have we learned from Yarnell Hill?

Granite Mountain
Granite Mountain Hotshots hiking to their assignment, June 30, 2013. Photo by Joy Collura.

It has been almost a year since 19 firefighters were killed on the Yarnell Hill Fire, June 30, 2013. The dust has settled near Yarnell, Arizona and many claims have been filed against various government agencies. One of those was converted into a lawsuit Monday when it was filed in Maricopa County Superior Court in Phoenix. It lists 162 property owners who name the state and the Arizona State Forestry Division as defendants. From the suit:

If the Arizona State Forestry Division had competently managed, contained and suppressed the Yarnell Hill Fire, no member of the Granite Mountain Interagency Hotshot Crew would have died. And Yarnell and its people would have escaped devastation.

That was the first of several lawsuits that will probably be filed. The second was issued Wednesday by 12 of the families of the firefighters killed in the fire.

While the sudden deaths of 19 people is horrific, it would ease our pain somewhat if we thought that something, anything, could come out of this that resembled lessons learned. If a few tidbits could be found in the ashes of the fire that could help others avoid a similar fate, maybe we could move forward with a glimmer of hope.

Reason swiss cheeze modelAn experienced firefighter can analyze the two official reports about the fatalities, and combined with reading between the lines and drawing conclusions based on their knowledge, they can nit pic using 20-20 hindsight like a Monday morning quarterback. We succumbed to what we saw as inevitable and after the second report came out in December wrote a piece listing 19 issues, or holes in the slices of Swiss cheese, that when combined, the holes align, permitting (in James T. Reason’s words) “a trajectory of accident opportunity”, so that a hazard passes through holes in all of the slices, leading to a failure.

We put the 19 issues into four categories: supervision of aerial resources, supervision of ground personnel, planning, and communication. This was not the first time these issues, or deficiencies have been seen on wildland fires. Communication, for example, is listed in almost every investigation report for a fatality on a fire. And it was not the first time that firefighters took on an assignment without an adequate briefing, without a current map of the fire, had incorrectly programmed radios, no safety officer, no written incident action plan, or that an incident management team arrived on the third day of a fire without any Division Supervisors.

When you combine all of the slices of the Swiss cheese and their 19 holes, failure is not inevitable, but it becomes more difficult to avoid. When a sleepy fire awakens and becomes complex all within the space of a few hours, it taxes the infrastructure that has been put in place. A robust organization can be resilient in the face of adversity, recovering quickly from difficult conditions, possibly even compensating for 19 holes. But if the organization and decision making, affected in some cases by little sleep over the previous 48 hours, is stressed and tested beyond its limits, undesirable results are more likely to occur.

It is conceivable that if one or more of the issues, or holes, had not occurred, we would not be mourning the 19 members of the Granite Mountain Hotshots.

One thing we don’t know about the fatalities on the Yarnell Hill Fire is why, exactly, the 19 firefighters walked into what became a lethal firetrap in a canyon. Nothing in the reports shed much light on how that decision was made, or by whom. It seems counter-intuitive that experienced firefighters would leave the safety of a previously burned area and expose themselves to the fire as they walked through unburned, very flammable vegetation, especially after a warning had been issued over the radio about an approaching thunderstorm cell with strong winds.

As the lawsuits work their way through the court system, the discovery process may yield information the government agencies that commissioned the reports preferred to be kept out of the public eye. Questions may be answered.

We can label them mistakes or unfortunate decisions, but what was done on the fire has been done before. Most of the time firefighters are lucky and get away with it, returning to their families when the fire is out. Other times they become documented in fatality reports.

While there may be few cultural changes coming out of this fire, other than perhaps being more aggressive and attacking new fires with overwhelming force, many firefighters and managers will move some basic safety principles closer to the surface of their ongoing evaluation of conditions on a fire. Supervisors may double and triple-check the location of their fire resources, and confirm through active listening techniques that orders and assignments are absolutely clear and understood. And that works both ways, up and down the chain of command. Fire managers could evaluate the supervision of aerial resources more often to ensure that the workload and span of control are within reasonable limits. Agency administrators could be certain that the management structure on a fire is appropriate for the complexity, and that “short” incident management teams are rarely if ever used. Transitions from one incident management organization to another may be watched more carefully.

Based on what we know about the fire, there is no earth-shaking revelation that can become a lesson learned. They have already been taught. Firefighters have been making the same mistakes for decades. They end up in reports that sit on shelves or hard drives. Unfortunately, another firefighter will repeat them. And they might be lucky, or resilient, and go home to their family when the fire is out.

Author: Bill Gabbert

After working full time in wildland fire for 33 years, he continues to learn, and strives to be a Student of Fire. Google+

11 thoughts on “What have we learned from Yarnell Hill?”

  1. Bill – an excellent analysis of what we can learn from the Yarnell Fire and the deaths of the Granite Mountain IHC. Unfortunately, this event will have a short “shelf life” as have other multiple fatality events: it’s in the forefront of our minds for a year or two, then fades away until another similar multiple fatality event occurs, often because of the same reasons. Will this cycle never end?

  2. All I can tell you is I was on that fire a year ago and my crew movied there trucks. I have many pics
    And videos leading up to the incedent. I have spent many days going over my pics and all the events that day. I put all my info together and have went over it to help people understand and at first I thought like you. There where many things that you could have said were holes in the cheese. After talking threw it and knowing several of them as well as going to over a dozen of the funerals. They were not risk takers and I truly feel that from where they were that it had to look totally reasonable and with little to know risk. Now is this ok NO one life lost is too many but as a fire fighter this job has Curtain risk and it scars me more now that if I was in there shoes I may have made the same decision they did. They are greatly missed and as far as leas sons leaden I feel that we can saftey our what out of doing nothing. It may be ironic but if they just made one more watch out witch it would be #19 I would hope there is a chance that we will see it often enough to make us think how they thought it was doable and how fast thing can change

  3. Agree with Ken…….

    Just let it get bigger through the “Control /Contain” method and then three days from now it will be all lights and sireeeeeeen ..

    Then send the troops ‘cuz now we gots to get all over ‘cuz now its out of our management plan and see what happens…

    IT IS amazing….because we have truly not learned any lessons through this method of operation

    Look out troops ( firefighters) this one does not seem worth lives especially looking at that topo…….BUT someone will sure think it is important to commit folks to……just watch…anyone bright enough looking at the weather the next few days and because one thunderstorm rolled through the area

    YIIIIKES

    1. We continue to learn every day and on every fire. The Eightmile fire is no different. If we don’t start taking a hard look at where the confine/contain strategy is appropriate we will suffer many more Waldo Canyon and Black Forest type fires. Will they all go exactly according to plan, probably not but the thought process and strategy is sound and I’m sure will continue to be used where appropriate. Let the professionals do what they are trained to do.

  4. There are two fire narratives:

    First, we are a hyper safety conscious society of professionals taking every precaution and making all the right moves because no house is worth a life. We protect resources because resources protect people. It doesn’t make sense to sacrifice people to save resources. Really?

    Second, we do point protection in the urban interface with young tough men and women who will climb any mountain, eat any meal. Wood smoke is good smoke. Hello! Point protection. Urban interface. What do those euphemisms mean? They mean we send good people to protect houses in the Red Zone. We are in denial about that. Kari Greer was castigated for taking photos of firefighters fighting fire with their sleeves rolled up, chewed on by camp slugs who wandered around the ICP trying to edit the historical record because they don’t know what it means to pick up a pulaski and face a wall of flame. Really.

    So we learned some things at Yarnell. We learned what Stephen Pyne will shortly say, that we will keep muddling through increasingly intense fires and fire losses and do the best we can because that’s who we are. Strap on your boots and hit it a lick. And quit pretending that firefighting isn’t a sometimes fatal pursuit.

    1. Good job, Frank – for a short while there, you really had me going! After my first reading of your post, I actually thought that you were following the John Wayne “Hellfighters/Green Berets” philosophy with your “strap on your boots and hit a lick” statement, and the closing comment about “quit pretending that firefighting is sometimes a fatal pursuit.”
      But after reading it again, I recognized that you were, in fact, using the “Stephen Colbert Model” of making your point: come out with some incredibly dumb statements, and let the absurdity of them filter thru to the listeners!
      Brilliant approach Stephen – I mean, Frank!

  5. Arizona Republic is running a series of articles this week on the fire. Today’s was about homeowners in Yarnell, and where they are at in recovery. One couple — who are part of the suit — wanted to rebuild with a log cabin …

  6. I like your analysis Bill and appreciate your efforts to bring perspective. The tragedy may not result in many new lessons learned. However, as you suggest, I think that remains to be seen. By the time these trials end, I suspect to know a whole lot more about the events of the Yarnell Hill Fire than I know now. While we should not expect that there will always be new lessons learned, an investigation should never distract firefighters or their employers from the important work of firefighter safety with peripheral issues, like VLATs and mitigation of fire threats on private property that had little, if any, bearing on the loss of the Granite Mountain Shots. May they rest in peace.

  7. Nothing has changed when property takes precedence over fire fighter safety….use your head boys, no house is worth dying for…retreat and live to try again tomorrow, the other option sucks….

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