USFS to use new serious accident review system

(Updated on August 9, 2014 to include a link to details about the new USFS policy, and on August 11 to correct information about the distribution of the version of the report prepared for “organizational leadership”.)

The U.S. Forest Service has created a new review process for serious incidents involving a fatality or three or more hospitalizations, called the Coordinated Response Protocol (CRP). According to the agency:

The CRP is a process now being used to ensure we learn everything possible from serious incidents so we can prevent recurrence while reducing the painful effects on those closest to the incident or accident by coordinating the investigations and reviews that are required when fatalities have occurred. The CRP uses pre-trained and designated response teams. This provides a basis for coordination and communication before any team is dispatched to an incident. This new process minimizes traumatic impacts on witnesses, coworkers and others close to the tragedy while improving our ability to gather information and learn. The CRP replaces the Serious Accident Investigation with a new process called the Learning Review. The Learning Review is designed to create learning products for multiple audiences.

A new Interagency Serious Accident Investigation Guide was used for the first report on the Yarnell Hill Fire on which 19 members of the Granite Mountain Hotshots were killed. The process prohibited causes, conclusions, and observations from being included in the public report; they were reserved for a second version of the report that would be for internal agency use only.

That process was a total failure and set a new low bar for learning opportunities following serious accidents. The USFS prohibited their employees that had specific knowledge about the fire from being interviewed.

The new protocol just introduced by the USFS also specifies that two reports be produced; one for the public and another for organizational leadership.

Ivan Pupulidy called us to say that he was the author of the new protocol. Presently he is the Acting Program Manager for Human Factors Risk Management Research Development and Application for the USFS’ Rocky Mountain Research Station. In September he will be the Director of the USFS’ new Office of Learning. Mr. Pupulidy said the agency no longer subscribes to the one-year old Interagency guide and explained that under the new system both versions of the reports will be published on the Wildland Fire Lessons Learned Center website. When asked if the causes, conclusions, and observations would be included in the reports, he said they “will not include traditional nonsense”.

Mr. Pupulidy said the information will be broken up into two reports, rather than just having one, because a single document became “lengthy and troublesome”.

Our view:

Some firefighters would argue that causes, conclusions, and observations are not “nonsense”, but are some of the more important and useful features of an accident report, and that banning them reduces the opportunities for learning and preventing similar accidents. Having subject matter experts review an accident and provide information about how and why it happened can be crucial information for those in the early stages of their career.

Any effective accident review must collect all of the information, and without censoring or overtly protecting agency officials, distribute findings that can reduce the chance of a future similar accident. As we found out, anything short of that is a waste of time and money. More than 50 people worked on the Yarnell Hill report, and could not pull it off. It sounds simple, but to get a politically sensitive agency to carry it out, apparently is very, very difficult.

In addition, innocent bystanders and witnesses with information about the accident must be protected from civil lawsuits and criminal charges.

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The USFS’ description of the new policy: Coordinated Response Protocol Paper

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 “USFS to use new serious accident review system”

  1. Learning every detail is impossible. The systemic root causes are plainly evident. The challenge is developing and implementing corrective actions to ensure that incidents are not repeated. If you want to call yourself and HRO – act like it and drive it.

  2. Bill is misinformed – there is no secret report. There is a perceived need for multiple learning products to serve multiple audiences. One audience is the Leadership of the Organization, the other is the Field. All reports (learning products) will be released and posted on the Lessons Learned website.

    In order to be effective, the Organizational Learning Product has to reflect the necessary staff-work to allow leadership to make informed risk based decisions. One of the major inputs into this process is derived through focus groups made up of subject matter experts (including Line Officers, academic specialists and operational personnel). These focus groups examine recommendations and challenge the assumptions contained in the team’s products. This is designed to prevent reactive mitigations that will not serve the purpose of prevention.

    The Field Learning products are based on the realization that learning occurs at different times, in different ways and by different people. Field learning products are unique, in that they do not tell people what to learn, instead they present information to make learning accessible through individual and group sensemaking practices.

    Field Learning products go through focus group analysis and review to determine how information should be formatted and presented to the field. In this way, field personnel who are familiar with the environment and culture, in which the event occurred, enhance the information collected in information collection phase. These focus groups also challenge any assumptions contained in the products of the LR Team and thus help to reduce bias.

    Our approach to accident reviews embraces the idea that knowledge resides in a large number of places, both inside and outside the organization and that developing collective knowledge is the responsibility of the review team. This approach is inclusive of multiple approaches to analysis, multiple perspectives and multiple sources of information. This means that teams must be humble enough to recognize that they may not have the answers to complex questions. Each of these reports will be posted on the lessons learned website. There will be a webinar this week to explain the new process.

    1. (This comment was written after Ivan wrote his, above, but before we received a phone call from him, in which he explained that he was the author of the new report protocol. We modified the article to include Ivan’s information that the “organizational leadership” version of the report will be released.)

      Ivan, I hope you are correctly informed about both versions of the report being released. If you are, it is not apparent in the four page description, a link to which we posted on the site.

      The Interagency Serious Accident Investigation Guide adopted last August by the USFS and other agencies (while the Yarnell Hill Fire investigation report was being prepared) included this:

      The Management Evaluation Report (MER) (Exhibit 7-5) is the second part of the Final Report and is intended for internal agency use only.

      It went on to say the MER would have confidential information, and would include other information the public report would not have, including causes, conclusions, and observations.

      The new USFS protocol is described in the four page description in a very brief, but similar manner:

      The Learning Review process is designed to produce at least two learning products, one for the field and one for organizational leadership. These products have markedly different audiences with very different needs in terms of learning.

  3. There was a time when people collected facts, interviewed people individually and thoroughly, analyzed things, and drew conclusions. How on earth did we get from there to a system embracing “group sensemaking practices?” Groupthink is a huge and, at least in the past, well-known threat to safety in the field.

  4. If we had a new transparent government,of which we the taxpayer support

    These types of miscommunication such as the one between Bill N Ivan would not be so prevalant

    The stuff that comes from the hallowed halls of the LMA’s such as SAIR’s are not even CLASSIFIED document……although I am sure there are some who would like to think they are some kind of DoD operation.

    Transparency…….a word only with NO action supporting it

  5. Hooooooo boy

    Now we have folks telling us we have “products ” for different needs in terms of learning…..

    Wow …now do we have certified teachers other than M-410 “qualified ” instructors telling us this? Are the practicing educators in the field of education…

    Hell……a Certified Flight Instructor (FAA CFI) is a more qualified “teacher” than some “Mangement Evaluation Team and Reports.”

    One product for the field and one for the organizational leadership?

    WOW…..Now we are separating the worker bees from the management……the Airline Pilots Association (ALPA) could see right through this one…..why do you suppose there is rift between management and Pulaski operators after viewing that little precious word smithing

    I learned from US Army Aviation……..the enlisted man and officers see the same books, regulations, SOP’s etc and see how to put those together without a lot of word smithing hogwash…….YEP we follow a chain of command…..but the USFS STILL has this “I/ we are in charge” and some sort of military like dream of “chain of command” that is / has been fraught a number of issues..

    I liked my tours with USDOI ( BLM and USFWS) who more realistic and had to do with what they had in more remote situations……and even they did not have these type of ego type issues

    Yep DOI……interested in fact and reality and less in pontificating….I AGREE!

  6. Chief of the Forest Service said we would be a zero fatality org. after being given safety cards and having a GS-14 recreation planner explain risk management to career hotshots and jumpers. So we don’t need to review anything it’s been covered
    P.S. Lots of sarcasm here if not obvious.

  7. The USFS and other agencies need to work to get the concept of privileged safety information [see http://www.dtic.mil/whs/directives/corres/pdf/605507p.pdf%5D enacted into legislation.

    Until the concept of privileged safety information is enacted for civil agency safety investigations and the findings are not subject to subpoena, witnesses are still going to “lawyer up” and the investigators aren’t going to get to the bottom line.

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