Investigation into the three fatalities in Washington begins

A team that will be investigating the August 19 fatalities of three U.S. Forest Service firefighters on the Twisp River Fire in Washington is being assembled. According to an article at OregonLive they will be using a fairly new protocol that we covered in August of 2014, called the Coordinated Response Protocol, or CRP. The controversial process minimizes traumatic impacts on witnesses, coworkers and others close to the tragedy, but strives to avoid developing causes and conclusions. As we reported last August, Ivan Pupulidy, one of the developers of the CRP, called causes and conclusions “traditional nonsense”.

Aside from the controversial nature of the CRP, OregonLive has a very informative article about the investigation into the Twisp River Fire, and how the team will be organized. Below is an excerpt:

…A team of investigators is arriving Thursday to begin the recently adopted Coordinated Response Protocol. The new rules seek to eliminate missteps on fatal investigations of the past.

“My heart breaks over the loss of life,” Gov. Jay Inslee said in a statement. “They gave their lives to protect others. It was their calling, but the loss for their families is immense.”

Officials often found that people assigned to investigate deaths or serious accidents were so focused on the task at hand they were insensitive to the victims involved during the interview process. The goal is to learn from what happened and take steps to prevent mistakes from happening again.

“It’s a smoother way to help the people involved because they are obviously traumatized,” said Mike Ferris, a spokesman for the National Interagency Fire Center in Boise. Ferris’ colleague, Jennifer Jones, will join the investigation Thursday as the information coordinator.

“It means the people affected by the incident don’t have to sit through 12 interviews by five or six different people,” Ferris said during a phone interview Thursday morning with The Oregonian/OregonLive.

The process were implemented with the July 30 death of David Ruhl, a U.S. Forest Service captain from South Dakota’s Black Hills National Forest. He died in a wildfire in the Modoc National Forest of Northern California.

A learning review replaces the serious accident investigation process with hope to “minimize the impact that reviews can have on the personnel who were involved in the incident while simultaneously meeting organizational and ethical requirements,” according to Forest Service documents.

Officials also hope briefing victims’ families during the new process relieves tensions that occurred in the past.

The goal is to provide “as clear a picture of what influenced actions and decisions as possible” even if it results in “uncovering hard truths that might appear contrary to protecting the agency,” the documents say…

The graphic below (of strangely faceless people) is from the USFS’ description of the CRP process.

CRP team structure

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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.

11 thoughts on “Investigation into the three fatalities in Washington begins”

  1. The ability to point out who screwed up and hold them accountable sooths the sole. This allows us to naively believe that we made the world a better place by doing so.

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  2. When you don’t mitigate the standards of the fire orders, bad things are bound to happen. A vehicle accident, even though apparently not the cause, is a separate factor.

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  3. The “Learning Review” portion of the CRP is similar to many other processes being used to learn from and educate, rather than blame and punish.

    The “Learning Review” process focuses on the “what” rather than the “who” and generates far greater learning after an accident than creating lists and assigning blame.

    Folks in high reliability organizations are very familiar with the process of lessons learned trumping the need to blame.

    The Serious Accident Investigation process that we used for 40 years obviously didn’t work as accidents were repeated over and over again.

    Folks… Give the new “Learning Review” process a chance before you jump to conclusions on what it does or does not do.

    IMHO

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  4. Would it be cynical to suspect that the CRP could be very sensitive and considerate of the feelings and reputations of the managers involved and may minimize production of material of use to any prospective litigation lawyers?

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  5. Wait…they’re going to do an investigation into what happened *without* attempting to figure out the cause *or* draw conclusions from doing so?

    Uhm…

    “WTF?!!!” is the only thing that comes to mind reading that. Isn’t the entire bloody *point* of an investigation to figure out how, what, and why something happened?

    That *sounds* – at least to a layman like me (I only developed an interest after Yarnell) – like a coroner announcing that he’s now going to perform autopsies without looking for the cause of death or drawing any conclusions from the exam. That is, he’s going to go through the motions, but that’s it.

    Am I missing something here? I’m all for protecting those hurt by the loss – but I’m pretty damn sure *they* would prefer answers to kid gloves!

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    1. Check out Sidney Dekker’s book, The Field Guide to Understanding “Human Error”. Will provide some background.

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      1. I’ve studied psychology – I have a basic understanding of it, although I’ll take a look at the book, too. Because – psychology courses or not – this just *blows my mind*. The “investigation” into how the GM 19 died was a *travesty* – an insult not only to the nineteen hotshots who died but to every wildland firefighter. To not find out the truth – however painful…well… “

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        1. I meant to say,

          “Those who do not know history’s mistakes are doomed to repeat them.”

          When the mistakes involve multiple fatalities multiple times, a refusal to properly investigate so they can know is criminal. Even if the theory that “came out” in early April about how they wound up in the canyon – I won’t name names – *is* true, there are *still* lessons to be learned there. Important ones. (Not to mention the communication issues that resulted in others not knowing where they were when they got trapped.)

          It sounds like this issue in Washington is totally different from Yarnell. But that *doesn’t* mean that pretending to investigate while not looking for causes is acceptable!

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    2. At the risk of sounding skeptical or insensitive to the feeling of those involved or the families of the deceased, this CRP process smacks of polical correctness and a touchy-feely accident investigation.
      Any bets if or when the National Transportation Safety Board (NTSB) adopts this CRP process for aircraft and train accidents? How about the Military services and their Lessons Learned branches?
      I guess we should expect another “Granite Mountain” quality report: everybody did everything right,. and 19 died. No Lessons Learned.” ??

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      1. Just *reading* that makes me angry all over again! Nineteen men don’t just…*die* in a fire for no bloody reason! Who shrugs and goes, “Welp, everyone did everything right – plenty of harm but no foul – move along, nothing to see hear folks!”

        Seriously?!!!

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      2. NTSB uses the lessons learned process in case you wanted to know.

        It is one thing to determine “controlled flight into terrain” (CFIT) and assign a cause and blame vs finding out and sharing why an experienced pilot did it.

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