Wildfire Sinners and Cool Heads

This video features Dr. Jennifer A. Ziegler’s research into the history, development, and implementation of the 10 Standard Firefighting Orders. After the 1956 Inaja Fire killed 11 firefighters near Julian, California a task force reviewed the records of 16 tragedy fires that occurred from 1937 to 1956, concentrating on the 5 fires that killed 10 or more people. They developed a list of what those fatal fires had in common, calling them “sins of omission which our trained men recognize as sins” — things that the firefighters otherwise knew what to do, but simply forgot in a critical situation.

Jennifer Ziegler
Jennifer A. Ziegler. Valparaiso Univ. photo.

The task force also looked at near misses that had a positive outcome. They decided those firefighters were successful because the “cool heads”, as they called them in 1957, sized up the changes in fire behavior in time to get the men to safety.

In the video Dr. Ziegler also talks about how beginning in the 1990s investigation teams studying fatalities sometimes used the Orders as a checklist.

Ms. Ziegler is known to many wildland firefighters through her research and conference presentations on communications in the management and practice of safety in wildland firefighting. Some of her findings were part of the 2009 standardized fire refresher training.

She has taught at Baylor, Purdue, Notre Dame, and Valparaiso University where she is now the Dean of the Graduate School and Continuing Education. Below is an excerpt from her profile at Valparaiso:

…In addition to her passion for graduate education, Dean Ziegler is passionate about conducting research in organizational communication that makes a difference. Dean Ziegler was first exposed to the culture of wildland firefighting while a graduate student at the University of Colorado. Throughout the last decade, Dean Ziegler’s research has focused solely on communication in the management and practice of safety in wildland firefighting. Her work at the intersection of rhetoric, culture, and communication theory has helped the fire community understand the history and cultural legacy of bureaucratic rules in accident investigations; as a result, she is frequently invited to speak at fire conferences, workshops, and refreshers.

She has also consulted with agencies on high-profile incidents and related initiatives, helping to illuminate cultural and organizational factors that may contribute to unwanted outcomes. Her recent work centers on how “talk about talk” (metadiscourse) shapes the way people interact during intentional culture change. Soon she will join an interdisciplinary team of scholars (including two of her former graduate students) on a Joint Fire Science funded grant to study risk perception and collective sense-making through radio communications on the fireline.

 

Do the firefighting orders and watch out situations need to be changed?

The “Safety Matters” group (“A Wildland Firefighter Forum for Change”), is asking for firefighters to express their opinions about the need, or lack thereof, of making changes to the 10 Standard Firefighting Orders and the 18 Watch Out Situations. On their Facebook page the group posted the following:

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“We agree that the 10 & 18 were designed for firefighter safety, to cover all safety bases on the fireline.

We would like to raise an important consideration. Fire seasons have become longer. Fire behavior is more extreme. There are numerous accounts of fire behavior that “outperforms our expectations”. The new normal is considered to be extreme fire behavior. Drought is rampant; fuel moistures remain critically low and do not recover. Global warming is discussed, and radical weather is seen across the globe. Red flag warnings are becoming typical, more homes are lost in the WUI, and more acres are burned each year. But more importantly, wildland firefighters are exposed to increasing risk while doing the same job.

The 10 Standard Firefighting Orders and the 18 Watch Out Situations were developed in past decades to reflect wildfire conditions at the time of their development.

Is it possible that the 10 and 18 need to be reevaluated, reassessed and reconfigured to reflect a changing fire regime, an increase in fire severity and an obvious shift in what firefighters can expect on the fireline, a shift to the extreme?

Certainly the 10 and 18 should exist in some standard form, but is it possible that they need our careful reevaluation in order to keep pace with and reflect our changing conditions and circumstances?”

New guide for accident reports requires conclusions and recommendations to be kept secret

New guide for wildfire accident reports requires conclusions and recommendations to be kept secret, intended for internal agency use only.

On Friday we wrote about some of the controversial issues that have surfaced in recent weeks related to the deaths of the 19 members of the Granite Mountain Hotshots on the June 30 Yarnell Hill Fire. One of them, covered by the USA Today, concerned the reports prepared by the Serious Accident Investigation team.

The latest Serious Accident Investigation Guide, revised just last month, was written by representatives of the five federal land management agencies and recommends that two reports be prepared. One, the Factual Report, would be made public, and the other, the Management Evaluation Report, would be confidential, and intended for internal agency use only.

According to the new guide released last month, “Only the facts go into the Factual Report— no inferences, conclusions, or recommendations.”

The confidential Management Evaluation Report would include:

  • Findings identified in the Factual Report
  • Cause(s) of the accident
  • Conclusions and observations
  • Confidential information (no witness statements or autopsy reports)
  • Recommendations for corrective measures
  • Other findings—findings not related to the accident which if left uncorrected could lead to future accidents/organizational failures (follow specific agency policy regarding other findings)

If conclusions and recommendations are kept secret, only to be seen by a few people, this would severely limit the opportunities to learn any lessons that could prevent similar tragedies.

These recommendations released in August, if followed by the teams writing the reports for the Arizona state government and others in the future, would result in public reports that are much different from those we have seen in recent years. Some that come to mind that include causes, contributing factors, or recommendations are the CR 337 Fire Fatality, the Steep Corner Fire Fatality, the Dutch Creek Fire fatality (huge 21Mb file), and the Sadler Fire entrapment.

The five people who wrote the new guide may be fearful of lawsuits and criminal charges which began after the 2001 Thirtymile Fire. Senator Maria Cantwell and Representative Doc Hastings, in a knee-jerk reaction to that fire, wrote the Cantwell-Hastings bill which was approved by Congress, signed by the President, and became Public Law 107-203 in 2002. It requires that in the case of a fatality of a U.S. Forest Service employee “due to wildfire entrapment or burnover, the Inspector General of the Department of Agriculture shall conduct an investigation of the fatality” which would be independent of any investigation conducted by the USFS.

Before the Thirtymile Fire the Department of Agriculture’s Inspector General’s office had no experience or training in the suppression or investigation of wildland fires. They are much more likely to be investigating food stamp fraud or violations at a chicken ranch than evaluating fire behavior and tactical decisions at a wildfire. The goal of the Inspector General investigation is to determine if any crimes were committed, so that a firefighter could be charged and possibly sent to prison.

After the trainee wildland fire investigator for the OIG finished looking at the Thirtymile fire, on January 30, 2007 the crew boss of the four firefighters that died was charged with 11 felonies, including four counts of manslaughter. The charges were later reduced to two counts of making false statements to which he pleaded guilty on August 20, 2008. He was sentenced to three years of probation and 90 days of work release.

This had a chilling effect on firefighters who are required to make split-second decisions that later may be second guessed by a jury with no clue of what it is like to be faced with a life and death situation on a rapidly spreading wildfire.

Since those felony charges were filed against a firefighter who may or may not have made an error in judgement while fighting a fire, most wildland firefighters with any connection at all to a serious accident have had reservations about talking to investigators. They are being advised behind the scenes to “lawyer up” and to say little if anything about what they know or observed. Many have purchased professional liability insurance which would help to defray the cost of hiring attorneys which otherwise could ruin the financial lives of underpaid government employees and their families.

The unintended consequences of Senator Maria Cantwell and Representative Doc Hastings’ legislation has changed fire investigations. If firefighters can’t feel free to discuss what happened on a fire, finding any lessons to be learned is going to be difficult. This could result in the same mistakes costing more lives.

It was just a few years ago that firefighters were told “we do not bend, we do not break” the 10 Standard Firefighting Orders, and you better obey the 18 Watch Out Situations. The new investigation guidelines and the Interagency Standards for Fire and Aviation Operations now describe them as:

…not absolute rules. They require judgment in application.

Accident investigators, including the amateurs from the Office of Inspector General’s office, have found it easy to use the Orders and Situations as a checklist, saying “x” number of them were violated. That later becomes fodder for attorneys in civil suits and prosecutors seeking to put firefighters in prison.

It appears that the writers of the new investigation guide placed more emphasis on preventing criminal charges and civil lawsuits than learning lessons when they decided to keep secret the conclusions and recommendations following serious accidents. They may feel they were forced into this very uncomfortable position because of the current lawsuit and criminal prosecution atmosphere.

How do we fix this?

The military has the benefit of a law that is the opposite of the Cantwell-Hastings bill. They have the protection of 10 U.S.C. 2254(d), which states that in the case of an aircraft accident:

Use of Information in Civil Proceedings.—For purposes of any civil or criminal proceeding arising from an aircraft accident, any opinion of the accident investigators as to the cause of, or the factors contributing to, the accident set forth in the accident investigation report may not be considered as evidence in such proceeding, nor may such information be considered an admission of liability by the United States or by any person referred to in those conclusions or statements.

Senator Maria Cantwell and Representative Doc Hastings need to suck it up and admit their knee-jerk reaction to the Thirtymile fire has caused a great deal of unintended harm. In 2001 they thought their ill advised idea might enhance the safety of firefighters, but it has accomplished the reverse. Lessons learned are becoming more difficult to uncover. Mistakes are more likely to be repeated because of their legislation which became Public Law 107-203. They wanted investigations, but investigations have always occurred following serious accidents. Their legislation had zero benefits, and had far-reaching negative consequences.

Senator Cantwell and Representative Hastings should feel a moral obligation to fix the problem they created. They need to craft legislation to protect firefighters, similar to that protecting the military in 10 U.S.C. 2254(d).

OSHA revises fine and citation for the Steep Corner Fire fatality

The Occupational Safety and Health Administration has agreed to reduce the fine and modify the citation they issued to the organization responsible for fire suppression on the Steep Corner Fire near Orofino, Idaho. Anne Veseth, a 20-year-old U.S. Forest Service firefighter from Moscow, Idaho was killed by a falling tree August 12, 2012 while working on the fire. OSHA issued a citation to the Clearwater-Potlatch Timber Protective Association (CPTPA) along with a “Notification of Penalty”, for fines totaling $14,000. OSHA also issued a Notice of Unsafe or Unhealthful Working Conditions to the U.S. Forest Service, but without a monetary penalty.

On Thursday CPTPA Chief Fire Warden Howard Weeks signed an agreement with OSHA that reduced the fine to $10,500 and revised the citation. Originally OSHA accused CPTPA of not furnishing a place of employment that was free of “recognized hazards that were causing or likely to cause death or serious physical harm to employees”. OSHA said eight of the 10 Standard Firefighting Orders and 11 of the 18 Watch Out Situations were present and not mitigated in the citation issued to the CPTPA and the Notice issued to the USFS.

Below is an excerpt from an article at Firehouse.com that originally appeared in the Lewiston Tribune:

Idaho Department of Lands spokeswoman Emily Callihan said the original citation would have made it impossible for firefighters to do their jobs.

[…]

Callihan said the 10 and 18 are guidelines and not regulations, and the hazards they cover are present on nearly every fire. But, she said, the OSHA citation, as originally written, would have required firefighters to leave any fire where any of the 10 orders could not be followed or any of the 18 situations were present.

“What OSHA eventually recognized, is by removing firefighters from fires where any of those situations are present would result in not being able to respond with initial attack and keep fires small,” she said. “So it would have resulted in having fires get big and present more of a danger to firefighters and the public in the long run.”

The day before Ms. Veseth was killed, the Flathead Hotshots arrived at the fire. After scouting it and assessing the situation, they concluded it was not safe to work under the conditions that were present. Then they left the fire after talking with the incident commander. Three days later they filed a SAFENET report documenting the unsafe conditions at the fire.

More information at Wildfire Today about the Steep Corner fire and the death of Anne Veseth.

OSHA issues citation for firefighter fatality on Steep Corner Fire

(Originally posted at 2:00 p.m. MT, Feb. 12, 2013; updated at 5:44 p.m. MT.)

The Occupational Safety and Health Administration (OSHA) has issued a citation related to the fatality of Anne Veseth, a 20-year-old U.S. Forest Service firefighter from Moscow, Idaho who was killed August 12, 2012 while working on the Steep Corner Fire near Orofino, Idaho. The citation was issued to the organization managing the fire, the Clearwater-Potlatch Timber Protective Association (CPTPA). The citation comes with a “Notification of Penalty”, fines totaling $14,000.

OSHA also issued a Notice of Unsafe or Unhealthful Working Conditions to the U.S. Forest Service, but without a monetary penalty.

Ms. Veseth was killed by a falling tree, when one tree fell and crashed into another tree, causing it to fall in a domino effect. The day before she was killed, the Flathead Hotshots arrived at the fire, and after scouting it and assessing the situation, they concluded it was not safe to work under the conditions that were present. Then they left the fire after talking with the incident commander. Three days later they filed a SAFENET report, documenting the unsafe conditions at the fire.

The Citation for the CPTPA and the Notice for the USFS were both dated February 7, 2013.

The CPTPA citation was for the following:

  • Serious violation: For not providing a safe working environment; 8 of the 10 Standard Firefighting Orders were violated, and they did not mitigate 11 of the 18 Watch Out Situations. Proposed penalty: $4,900.
  • Serious violation: employees engaged in wildland firefighting were exposed to being struck by hazard trees while constructing fire line.  Proposed penalty: $4,900.
  • Serious violation: Firefighters constructing direct fire line did not have fire shelters readily available. Firefighters constructing fire line were wearing denim and work pants not rated as fire resistant. Proposed penalty: $4,200.

The U.S. Forest Service Notice of Unsafe or Unhealthful Working Conditions was for the following:

  • Serious Violation: 7 of the 10 Standard Firefighting Orders were violated,  and they did not mitigate 9 of the 18 Watch Out Situations.
  • Repeat Violation: employees engaged in wildland firefighting were exposed to being struck by hazard trees while constructing fire line.

If the violations are not contested they must be abated by various dates in March, 2013, and the fine must be paid within 15 working days.

Lead by Example Award: Bud Moore

The Paul Gleason Lead by Example Award has been given posthumously to William R. “Bud” Moore, who passed away in November. Mr. Moore retired in 1974 as the Director of Fire and Aviation for the U.S. Forest Service’s Northern Region. On November 30, 2011, Wildfire Today posted excerpts from article about his career that ran in Smithsonian Magazine, including the fact that he helped to develop one of the first prescribed natural fire programs in 1972.

Last month, another Lead by Example award was given to a group of personnel on the Black Hills National Forest.

The document below was prepared by Bill Miller of the USFS’ Missoula Smokejumper Program.

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Bud MooreWilliam R. “Bud” Moore ventured on to what he considered “The Big Trip” in November of 2010.  During his time here with us, Bud exemplified the concepts of Service and Leadership.  Officially, Bud served his nation for over 40 years, starting with U.S. Forest Service as smokechaser and forest guard on the Powell Ranger District 1934, and Retiring as the Director of Fire and Aviation for the USFS’ Northern Region in 1974.  Bud spent three of those years serving in the 1st Marine Division during World War II in the South Pacific Campaigns, and attained the rank of Gunnery Sergeant.

Upon his return to the states, and the U.S. Forest Service, Bud quickly jumped back into a life of dedication to the land he loved so much, and to the people that worked it.  When he rejoined the USFS, Bud spent time as a Fire Control Aide, and a Forest Ranger on the Powell Ranger District of the Clearwater NF, where he made a home for Wag Dodge following the devastating fire in Mann Gulch, 1949. Bud then went on to become a Staff Forester and in 1959 was promoted to Safety & Training Officer of the Intermountain Region, where he was Instrumental in the development and the implementation of the 10 Standard Firefighting Orders and the original 13 Watchout Situations.

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