FIRE SAFETY: UP IN SMOKE?
Ted Putnam, Ph. D. -Psychologist
The safety record of the 2000 fire season was a good one and a credit to
firefighters. Ironically, this was due partly to the intensity of the fires.
Aggressive tactics were clearly imprudent in the face of massive flame fronts and aberrant
fire behavior. These conditions dictated (and justified) a conservative approach
where firefighters spent less time in harm’s way.
So the 2000 safety record was more a function of the fires themselves rather
than any objective organizational changes that made the fireline a safer place.
In fact, there remain inherent safety problems in wildland firefighting that go
unaddressed and which make substantive safety reform impossible.
While a Forest Service employee, I investigated many of the entrapments that
occurred in the past twenty plus years. In my early years as a firefighter I was
told and believed that fire management provided safety fixes after “the ashes
had settled.” Because of that belief, I helped cover up the real causes of the
fatalities on the Battlement Fire in 1976. I bit my tongue on many more,
including South Canyon in 1994 and Sheppard Mountain in 1996, due to
promised improvements. As the promises faded, I began to speak up at
firefighter conferences because if fire safety is ever going to be “fixed,” the
causes of fatalities, injuries and near misses must be clearly understood. If
organizational safety practices and training are based on the “official
which many times are not based on the facts, how effective can these practices
In this article I outline six areas in which firefighter safety has improved
despite clear lessons like South Canyon.
Lack of fire management support for human factors.
When looking at the fatalities, accidents, near misses and unsafe actions,
fire organizations historically have focused on physical causes and
ignored mental and cultural causes – the human factors. The rule of
thumb among safety experts in the military and private sector is that only
20 percent of the causal factors are physical, while 80 percent are mental
or cultural. If safety is to be No.1, on the fireline why have wildland fire
organizations suppressed or minimized the mental and cultural causes of
Recent examples where human factors (mental and cultural) aspects of
accidents were largely ignored includes: (1) mediocre entrapment
investigations, many of which involve cover-up’s and misinformation
(South Canyon, Shepard Mountain); (2) forcing human factor concerns to
be removed from the 1998 Butler et al. report; (3) under funding then
canceling the human factors effort at the Missoula Technology and
Development Center (MTDC), including the human factors newsletter
(USDI, 2000); (4) the Center for Lessons Learned at Marana tracks only
physical causes (USDI, 2000); (5) the new incident reporting system
tracks physical and equipment causes, but ignores human factors; (6)
failure to adopt Crew Resource Management (CRM) for firefighters after it
was recognized nationally as a need that had the potential to reduce
accidents and fatalities by 50 percent.
Why safety is not No. 1.
Safety has never has been No. 1 and may never be.
What then are the
behaviors that compete with safety? After many discussions with
firefighters and 35 years in the fire organization, in my opinion they are in
order of potency and priority:
- Putting the fire out. We are a can-do organization. This is the most
heavily reinforced behavior on the fireline and most likely the leading
cause of fatalities. See South Canyon Fire (USDI, 1994) and Sadler
Fire (USDI, 1999) for examples.
- Financial concerns. Personal financial incentives, while necessary, too
often bias firefighters to work to the point of mental and physical
deterioration, making accidents more imminent. This is more likely a
cause of injury and near misses than fatalities. Fire managers and
Incident Management Teams often under spend to save money in
initial fire outbreaks. This results in insufficient resources attacking the
fire. This alone or in combination with factor No. 1 puts firefighters at
risk and can lead to fatalities (South Canyon, 1994).
- Self and/or crew image. Who am I and who are we if we fail to put out
the fire? We love to discuss and take pride in what we do. We don’t
brag about the one that got away or the one we chose not to fight (but
we should when it involves excessive risk, i.e. the Sadler Fire). Esprit
de corps can turn into excessive risk, especially when the public,
media, and politicians are watching (Weick, 1995).
- Agency/ Fire Organization image. The argument here is similar to self
and crew image. We strive to accomplish No. 1 so the image of all
firefighters is enhanced. This factor is more potent when we try to
minimize an agency’s causal connections to fatalities such as BLM fire
management on the South Canyon Fire (Maclean, 1999). Interagency
cooperation is the reason cited for allowing BLM smokejumpers to use
inherently more dangerous parachutes (ram-airs) on USFS lands when
much safer parachutes are available (rounds). This factor, image
before safety, can be a primary barrier to fire organizations becoming
learning organizations. See Karl Weick’s book: Sensemaking in
Organizations and Peter Senge’s The Fifth Discipline.
- Safety. Here safety is the concern for self and others. For safety to
move up the list firefighters and agencies must look more closely at the
higher reinforced factors and how to reduce or neutralize their potency. Firefighters must learn to think more clearly and then take the relevant
factors into account before committing to strategies and tactics. And
they must mindfully review the associated risks, especially following
changing fire behavior and weather conditions. See my related article
Mindful Of Safety (2001) recommending the practice of mindfulness.
Failure to change. A reoccurring factor in many accidents and fatalities
is the failure to change strategies and tactics when fire behavior
changes. Incident Action Plans often are mindlessly followed and push
others into unsafe, potentially life-threatening actions (Shepard
Mountain Fire, 1996) even though the conditions they were based
upon no longer exist. This factor is often more potent than No. 5.
No one can follow the 10 standard fire orders.
It is humanly impossible to follow the 10 Standard Fire Orders and still
fight the fire.
How did this come about? What do we mean when we say,
“We don’t bend them, we don’t break them”? In discussing these issues
with fire managers, they say the orders pertain to each and every
firefighter-not just to the crew superintendent or the crew collectively. Since no one can follow them, it is not surprising that investigations into
fatalities and accidents show some or all were violated. Using the 10
Standard Fire Orders and the 18 Situations that Shout Watchout is still
SOP for wildland fire entrapment investigations (Sadler Fire, 1999) even
though such methodology is considered archaic and much better
methodologies exist (Munson, 2000).
What is a personal example? Look at order No. 5: “Obtain current
information on fire status”. The behavioral problem here is that as soon as
you make any fire observation it becomes a static conceptual memory and
a moment later it is no longer current. A picky detail? Not when you
consider how your mind processes information. We make decisions on
the past remembered fire behavior (concepts) rather than the current fire
behavior. Normally the direct perception of the actual fire behavior is short
circuited by the concept, which has only a fraction of the information of a
direct perception (de Charms, 1998). Most of the time we are unaware of
the conceptual substitution and the corresponding gaps in our perception.
To learn more about the underlying psychology refer to Daniel Goleman’s
Vital Lies, Simple Truths and Karl Weick’s Sensemaking in Organizations.
Now consider a management example. Whenever I hear a fire manager
say we don’t bend or break the 10 Standard Fire Orders, I issue them the
challenge to identify which, if any, should never be broken. Their normal
answer is all of them. But if I clarify, that the same fire order then becomes
the basis for never engaging a fire and the basis for disengaging the fire if
it can’t be followed, they go strangely silent. To date I have not had a
single Fire Order recommended by anyone, once the clarification and
added contingency are stated. Clearly, fire management wants and enjoys
a system where they can seldom be held accountable.
Most wildland fire entrapment investigations involve covering up evidence.
Often these actions are done deliberately but sometimes they are done
out of ignorance. Why do we do this? Deliberate reasons include: (1)
other organizations do it (such as structural fire departments, the military,
etc.). (2) The agency will be sued if we don’t. (3) Key individuals have
suffered enough. (4) The agency will look bad. (5) We’ll correct the
situation when “the ashes have settled,” i.e., South Canyon IMRT effort.
Cover-ups, involving ignorance, include: (1) sending untrained people to
investigate the entrapment (a favorite of wildland agencies). (2) Don’t
send someone who is getting wise to all the ways to cover-up evidence
(as happened to me after the South Canyon Fire). (3) Send interested
parties as investigators (biased towards covering up) (USDI, 1994). (4)
Send only people with firefighting expertise, as that is primarily what they
will notice and report (no psychologist or sociologist allowed). (5)
Removing evidence before the team arrives (another favorite). (6)
Ineffective interviewing skills that lead to short, incomplete accounts, i.e.,
lack of sufficient detail to understand the underlying causes. We then
report all the superficial old favorite causes and can recommend the
perennial “back to the basics” (South Canyon Fire, USDI, 1994). If it’s not
reported, you don’t have to fix it and can’t be held responsible for similar
Active concern for safety is punished.
This is usually passive punishment (withholding something normal or
positive). An example of passive punishment is when I was no longer
allowed to go on entrapment investigations when I did not sign the South
Canyon report. Sometimes punishment is subtle, like labeling safety
recommendations and presentations as “Mickey Mouse.” This safety
attitude is very visible organizationally since safety is poorly positioned,
funded and staffed at all levels of government showing it’s true importance
with top management.
We are a long way from becoming a learning organization.
Senge (1990) defined a learning organization as one “where people
continually expand their capacity to create the results they truly desire,
where new and expansive patterns of thinking are nurtured, where
collective aspiration is set free, and where people are continually learning
how to learn together”.
We will continue to put people at risk if we never learn from our mistakes.
Multiple fatality reports, such as South Canyon, look all too similar to those
generated as long as 40 years ago; a sure sign of management failure. A
persistent and vital need identified as a remedial action for more than 40
years is an incident reporting system (similar to the airlines). If safety is to
ever be No.1 why has such an easy remedial action taken so long to
implement? The data generated by such an IRS would become a baseline
for assessing if organizational changes reduce accident frequency. Both
the incident reporting system and the need to become a learning
organization were identified in the first human factor conference in
Missoula (USDA, 1995) as well as the follow-up 1999 conference in Reno
(USDI, 2000). Fire management has also been slow to implement Tri Data
recommendations, which are a large part of what has been learned so far
to make fire culture safer.
Currently the fire organization is not very proactive in making safety a
influence in strategies and tactics. Getting the job done, money and image
concerns push firefighters into taking excessive risk. What is needed
organizationally is truthful fire investigations, an honest reporting system
tracks physical, mental, cultural and social aspects of firefighting and a
willingness to become a learning organization. If safety is ever to become No.
1 in the fire community then the fire community must be willing to spend more
time, money and effort to make it No. 1. The fire community must get beyond
its superficial practices like saying over and over again that safety is No. 1
without any true, longer-term, institutionalized commitment. Part of this
commitment should involve adopting CRM throughout the organization,
following-up on the Tri-Data contract recommendations and promoting clearer
thinking through the practice of mindfulness.
Butler, B.; Bartlette, R.; Bradshaw, L.; Cohen, J.; Andrews, P.; Putnam, T.;
Mangan, R.; Fire Behavior Associated with the 1994 South canyon Fire on
Storm King Mountain Colorado (USDA-USFS-RMRS-RP#9) 1998.
De Charms, Christopher, Two Views of Mind (Ithaca, Snow Lion) 1998.
Goleman, Daniel, Vital Lies, Simple Truths: the Psychology of Self Deception
(New York, Simon and Schuster) 1985.
Maclean, John, Fire On the Mountain: The True Story of the South Canyon
Fire (New York, Morrow) 1999.
Munson, Steve, Assessment Of Accident Investigation Methods For Wildland
Firefighting Incidents By Case Study Method, Masters Thesis, University of
Montana (Missoula, Montana) 2000.
Putnam, Ted, Mindful Of Safety, short version:( Jackson, Wildfire) May/June,
2001 and long version:( email@example.com ) 2001.
Senge, Peter, The Fifth Discipline: The Art and Science of The Learning
Organization, (New York, Doubleday) 1990.
Tri Data Corporation, Wildland Firefighter Safety Awareness Study: Phase III-
Implementing Cultural Changer for Safety, (Arlington, Tri Data) 1998.
USDA Forest Service. Findings From the Wildland Firefighters Human
Factors Workshop, (Missoula, USFS-MTDC) 1995.
USDI Bureau of Land Management. South Canyon Fire Investigation,
(Phoenix, USDI-BLM) 1994.
USDI Bureau of Land Management. Sadler Fire Entrapment Investigation,
1999. At www.blm.gov/fna/.
USDI National Park Service. Human Factors Workshop (Boise, USDI-NPS),
Weick, Karl E. Sensemaking In Organizations (Thousand Oaks, Sage
Weick, Karl E. South Canyon Revisited: Lessons from High Reliability
Organizations in USDA, 1995.