Crews don’t make mistakes, they make decisions.
A few seasons ago, on a smoke-tinted evening in a fire camp in northern California, I wept. Didn’t expect to, but a lone bagpiper sighed into “Amazing Grace,” and I didn’t see an unstained cheek among 150 people. The previous week, a wildland firefighter had been burned over and killed on the incident. I never met him and wasn’t in the vicinity, but when the pipes lay into you …
I was unsure who or what I was crying for: the dead man, his survivors, myself, firefighters in general, the unforgiving nature of life and death for all?
Similarly, two weeks ago, when I heard about the 19 members of the Granite Mountain Hotshots who were entrapped and killed in Arizona, one of my first reactions was an undifferentiated anger. At what? At whom?
There’s history here. On Aug. 5, 1949, at Mann Gulch in Montana, 13 U.S. Forest Service firefighters were caught on a 75 percent slope in fine, flashy fuel, and lost an uphill race to relative safety on the lee side of the ridgetop. On July 6, 1994, I remember standing in our living room when I heard a radio report that 50 of my colleagues were missing on a wildfire at Storm King Mountain near Glenwood Springs, Colo. My knees actually softened, and I sat heavily on the sofa. Soon it was clear that 14 had died, caught on a steep slope in volatile fuel, losing a race to the crest of the ridge.
The wildland fire community was stunned. Similarities between the two events prompted a question: Did we learn nothing in 1949, or if we did, had it been forgotten?
Two weeks later, I was dispatched to a large fire in Washington state, and the altered mind-set was palpable. One reason that particular fire got big was because leaders on the incident were suddenly risk-averse, with crews held back from aggressive suppression tactics that would have been par for the course the month before.
In 1995, in response to the slaughter at Storm King (and remembering Mann Gulch), the Forest Service convened the “Human Factors Workshop” in Missoula, Mont. In addition to veteran fire ground leadership, participants included psychologists, sociologists and military trainers. Their purpose was neatly encapsulated by a headline in a local newspaper: “After 80 Years of Studying Fire, The Forest Service is Now Studying Fire Fighters.”
In other words, why do fire personnel under stress react, decide and think the way they do? And how may human behavior be modified when need be? One example: Firefighters trying to outrun the flames at Storm King did not jettison heavy packs and tools, when common sense (and later testing) indicate you can move up to 30 percent faster without the weight. Why?
The workshop was a seminal event, and its findings, published in booklet form, initiated significant change in the wildland fire culture. A suite of challenging leadership courses was developed; annual safety refresher training was mandated nationwide; human-factors principles, despite the perceived “touchy-feely” aspect of some psychological precepts, were built into many of the more technical courses and into operational protocols.
On page 14 of the findings, many of us were brought up short by the following statement: “Good crew supervisors do not focus on safety [what?], but rather on good supervision, crew cohesion, and work ethics. Safety is the result.” Supervisors, the paragraph went on, “who constantly talk about safety have more accidents than those who focus on working relationships.” In short, safety has to be built into the system, and is a byproduct of deeper personal and organizational commitments.
The message resonated, and in a few years most of us were familiar with mental tools such as situation awareness (SA), leader’s intent, after-action reviews, command presence, direct statements, the risk management matrix, personal communication responsibilities, self-assessments, Recognition Primed Decision-Making, high-reliability organizing (HRO) and crew resource management (CRM).
As an instructor and a line firefighter, I noted the mutation. In the midst of fire operations, you’d hear someone call out to a colleague, “How’s your SA?” At a briefing, a division supervisor would say, “Here’s my leader’s intent.” In classroom discussions and during tactical decisionmaking games, participants were role-playing the axioms of leadership and communication. As every responder knows, in an emergency you will likely perform only as well as you train.
No one was under the illusion that the annual tally of firefighter fatalities would reach zero, but it did seem possible to avoid mass-casualty episodes.
Perhaps that was one source of my anger — the hope of the human factors dashed. Not by 13, not by 14, but by 19 corpses.
Please understand two points. First, we don’t know precisely what happened at the Yarnell Hill Fire on June 30. The results of the investigation are weeks, if not months, away. Second, when a report does emerge, stakeholders must resist the temptations of hindsight bias.
Mark van Appen, a California firefighter, wrote: “Aggressive fire companies do not make mistakes in the heat of battle — they make decisions. Decisions are based upon the perception of the environment at the time.”
No member of the Granite Mountain Hotshots woke up that Sunday morning and thought, “You know, I’m going to go out and get myself killed today!” Whatever decisions they made probably appeared sound at the time. Nothing is easier than critiquing after the fact, and assigning full responsibility to the dead. It’s possible the crew was simply unlucky — in the wrong place at the wrong time through no direct fault of its own.
The chief purpose of any incident investigation should be to illuminate what can be learned to avoid a similar outcome under similar conditions. In the fire service culture we’ve been striving to create since 1995, actual blame takes a backseat. Mark Smith of Mission Centered Solutions, a developer and presenter of leadership courses, wrote: “Real discipline is reserved for willful violations of policy or for gross negligence. Everything else is considered a learning opportunity.”
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