Tag: human factors

Below is an article written by Rowdy Muir, a Type 1 Incident Commander, that appeared in the Bureau of Indian Affairs’ Smoke Signals publication this month:

What We Already Know

By Rowdy Muir, Agency Administrator Representative, National Interagency Hotshot Committee

Editor’s note: This article was written several months before the investigation report was completed and released.

On the evening of June 30, 2013, the news confirming that nineteen hotshots had died on the Yarnell Hill Fire shocked not only the fire community but the whole nation. I know there were others like myself who were wondering how something so tragic could happen to nineteen hotshots.

In 1994, after the South Canyon fire fatalities, people were asking the same question. Many were convinced that the investigation report would tell a story of some unrealistic, freakish event that claimed the lives of fourteen wildland firefighters. Yet nothing came out in the report that was unusual, phenomenal or bizarre. It wasn’t an act of God. Instead, the reality is that as a culture we read about things we were familiar with—things we should have already known.

I anticipate the same realization when we find out what happened to the Granite Mountain 19 on the Yarnell Hill Fire once the investigative report is published. My bet is thereport won’t tell us anything new hashappened. We will once again find outsomething we already know.

Make no mistake, the investigation report is valid and essential to a learning culture—perhaps even more so if it is predictable. The content will likely focus on LCES, human factors, situational awareness, values, crew cohesion, bowls, chutes, chimneys, down drafts, column collapse, point protection, tactics, strategies, independent action, WUI, structure protection and downhill egress. All topics we’ve heard before and have had many discussions about. Yet for a small amount of time, topics that were not remembered.

Gordon Graham says this “there are no new ways to get into trouble.” This rings true for the wildland fire culture.

I don’t think there will be anything that will happen which is so new or different from what has happened in the past. Somewhere down the line, we’ll see that we’ve made the same mistakes as before.

I appreciate the honest openness of Darrell Willis (Cofounder Granite Mountain Hotshots) in his interview with the news media. What he shares gives me a lot of personal mental anguish. No one has all the answers to all the questions. But the following are some things we already know:

LCES

In the news conference with crew cofounder Darrell Willis he mentions that “one of the most emphasized things we do is to establish LCES.” Yet, in the same sentence he mentions that “there are points during the day that we didn’t have [LCES] in place.”

How many times have we heard that said? If we don’t have LCES in place then there is something wrong. Even if it’s only for a moment—one might bring to the attention of others the need to establish LCES. LCES needs to be continually monitored throughout the shift. If they are not in place, then we don’t engage until they are in place.

Tactics and Strategy

In the same interview, Darrell talks about the crew abandoning a tactic of anchor and flank to address some independent action (to do point protection on the structures). Most agree that independent action is critical to the success of catching many wildfires. What we need to learn from this is that when we change tactics and strategies that are working, we need to evaluate the risk vs. gain. We need to think things out before we engage in another tactic. Someone might ask, “Why are we leaving something that’s working to take the risk of something that may not work?”

Downhill through Bowls, Chutes, and Chimneys

Eric Hipke, the only survivor from the uphill run that proved fatal for others at South Canyon, may tell you that the there is only a 1 in 14 chance of out-running a fire burning up hill. Anytime we commit to any type of downhill egress, the option of successfully going back up the hill in an emergency is “slim to none.”

This is partly because it is so difficult to measure how long it takes to get back up, and then over or through these geographical barriers. We should reevaluate any type of downhill operation, knowing that the only way to safety is back up the hill.

The Value of Situational Awareness

In an interview with Juliann Ashcraft, she mentions the text she received from Andrew about how “things are getting wild,” and how “Yarnell was looking to burn.” She acknowledges that those words weren’t common language for Andrew. It was a different scenario which she hadn’t heard from him before. Her situational awareness told her that something was different.

Why is it that Andrew didn’t recognize the same awareness? Many of us recognize changes in our surroundings, and have “situational awareness.” However, even though we are aware of our surroundings, we sometimes fail to take intelligent action based on what we observe. We get caught up in the moment and sometimes our field of focus narrows, and we don’t rely on someone else to help us with our blind spots.

We need to recognize that when the slightest thing changes we need to adjust. When I first learned to ride bulls, I was taught that when a bull makes a move you need to make a counter move equal to the bull’s move. If you made a move that was too extreme or not equal to the bull’s move, it was much harder to react to the next move the bull made. In most cases, if you can’t make counter moves equal to the bull, the consequences are you got thrown off. It takes many years of practice to be able to compensate for either over-aggression or the lack of equal aggression.

I find this to be true with situational awareness. We need to be able to recognize the change and make decisions to equalize the change. Sometimes we either overreact to the change or ignore it; the consequences are the same. We become out of balance.

Weather and the Collapse of Columns

In discussions with personnel who were on the Dude Fire, I found out that no one really recognized the collapsing column that brought about what they thought was a weather event with rain, hail and strong down drafts.

I am currently the District Ranger on a district that had three fatalities related to a similar weather event. I was on an incident in Utah a few years ago in which a homeowner had me come look at his residence which had burned down. He wanted to know why.

He couldn’t understand why the front of the yard where he had parked a truck and tractor was still green and the vehicles untouched. The front of the residence would have been the head of the fire being pushed down valley from down drafts. One would have thought all his property would have been lost. In reality the weather event caused spotting way ahead and down valley of the main fire and when finished, the fire consumed the residence from the back side because the fire took a normal route of burning uphill.

The Yarnell Hill fire had experienced some of the same types of weather events throughout the day. Those events were broadcast by radio to those on the fireline.

Whether what happened was caused by a column collapsing, a frontal passage, or the buildup of clouds which resulted in down drafts, fires that experience these types of weather occurrences should make us mindful that there is really no main or head of the fire. An established fire can, and will come from all directions once down drafts occur.

WUI and the Values at Risk

The days of “anchor, flank and pinch” were the days of firefighters being out in the woods chasing fire that didn’t have much in the way of “values at risk.” The only “values” we were asked to watch out for were ourselves. It’s rare anymore to have a fire that doesn’t include many different “values at risk” that need protecting. The perception of these “values” takes away from the real mission, and that is again, to protect ourselves as we are the real and primary “value at risk.”

Our training curriculum is fairly narrow and focuses on the mission of wildland fire. Keep this in mind: you are truly the only “value at risk.” We are truly the only value that needs to be protected. And yes, I would say the protection of others falls into the category of “we.”

No one would ever downplay the value of other lives at risk. Somewhere in our culture, our perception changed and we took upon ourselves the responsibility of structure protection. This has never been our mission or our responsibility.

I believe when we get into a WUI situation, we really need to evaluate our thought process. This situation gets our adrenaline pumping, and blurs our ability to make sound and rational decisions. Especially if we are familiar with the community or know who lives in the houses. It’s much harder for us to disengage when we have an emotional attachment to the structures in addition to the people who inhabit them.

I know all too well the emotional aspect. When I was in Florida in 1998, working in and around various communities, I grew to know and like the people in those communities. As time moved on, the aspiration of trying to save every home in every community became a personal challenge and obligation. On one occasion, we were being run over by fire and doing the best we could to save structures. During the heat of the battle, I recognized my shortcoming and pulled everyone out of the situation. The need to reassess the situation is obvious now—yet for that small momen,t I was caught up in an unrealistic task. Pulling back was the best move I ever made. The perception is real. Don’t think for a moment you can’t get caught up in it.

Values and Crew Cohesion

All decisions are based on values. I believe we should share our personal values with our co-workers and team members. The more we share our values, the more cohesive we become. If we know and understand the values of our team members, we can appreciate and accept their decisions more easily. I find this to be critical in our quest to become better team players.

Teams, as a group, also have shared values. We make decisions based on what our team’s values are. If we accept the team values, then the team reaps the rewards or pays the consequences as a team. If we only navigate by our own values, then the rewards or consequences are only ours.

There are a lot of rewards from being on a team that succeeds or excels. We see this in the film story of the 1980 US Olympic Hockey team winning gold or Shackleton’s crew navigating their way home through the Antarctic. We see it in our modules, crews, sections, and staffs.

Each individual had to give up some personal values for the team to be successful; some personal and team values don’t mix. The reality is when decisions are made as a team—when there is a consensus that “this is what we are going to do, or not do”—a team owns the decision; and the team may lose. Our value system can compromise our situational awareness.

There are no new ways to get into trouble. Our culture has been here before and I’m quite certain we will be here again—an acknowledgment that may or may not help us heal depending on how we choose to process the information—the “what we know.”

If we take what we already know and put it to good use, it will help us come to the full understanding of the real, tangible, human values at risk.