Date: November 14, 2001
of the Thirty Mile Fire Accident Investigation
Committee: Senate Energy and Natural Resources,
Subcommittee on Public Lands and Forests
Members: Committee Chairman Bingaman (D-NM);
Subcommittee Chairman Wyden (D-OR); Senator Cantwell (D-WA); Senator Craig
Witnesses: Rep. Doc Hastings (R-WA); Dale Bosworth,
Chief of the Forest Service; Jerry Williams, Forest Service, Director of Fire
and Aviation Management; Ken Weaver, Father of Devin Weaver; Paul Gleason,
Professor of Forest Sciences at Colorado State University; Phil Schaenman,
President, Tri Data, Inc.
Opening Remarks: Chairman Bingaman said that fire
and threats of fire are an ongoing concern of bipartisan concern in many States.
He noted that Congress provided agencies with full funding of all aspects
of the National Fire Plan, including firefighting.
He said the Congress has held many hearings on fire policy and that the
federal land management agencies tell Congress that firefighter and public
safety is the number one priority. He was troubled to learn that Forest Service personnel made a
number of tragic mistakes relating to safety and those mistakes resulted in the
deaths of four firefighters. The
Chairman said the action plan resulting from the 30 Mile investigation will
improve the situation but constant oversight by the Subcommittee is necessary.
Chairman Wyden stated he wanted to be sure the four
firefighters’ lives were not lost in vain.
This means a new direction for the Forest Service and there will be a
bipartisan effort by the Subcommittee to be sure that people are accountable.
He said the action plan resulting from the 30 Mile investigation is a
step in the right direction.
Senator Craig said he wanted to understand what is working
and what is not working. He pointed
out that federal agencies have to do everything possible to prevent fatalities.
He was troubled by the
similarities of the 30 Mile fire to other fires where there have been fatalities
and that safety efforts must be redoubled. He said fire needs to be fought
aggressively with all the tools available and a key to this is to reduce fire
fuel loading. He said he expected
fire managers to get on with the National Fire Plan and reduce hazardous fuels.
Senator Cantwell began by stating that Congress was taking
the first steps to examine the safety performance of the Forest Service and
appropriate actions to be taken. She
said firefighting is dangerous and we owe it to those who have been killed or
injured to investigate their deaths, learn the causes, and learn from the
mistakes. She said she was troubled
by the fact that there have been several significant interagency reviews on
firefighter safety and yet the deaths at 30 Mile Fire still occurred.
She said it appears there is a gap between the safety policies and
procedures and what happens in the real world.
She asked why are safety policies more rhetoric than practice.
She said cultural and institutional lack of accountability of leadership
shows up in the Tri Data report and was a factor in past firefighter deaths.
First Panel: Rep. Doc Hastings (R-WA) thanked the
Chairman, the Subcommittee, and Senator Cantwell for having the hearing.
He noted the tragic deaths of four firefighters left many bereft.
He said all must work to ensure the safety of firefighters by seeking
policies that guide them through difficult situations.
He wondered why the Forest Service apparently failed to adequately follow
through on assurances that changes would be made after the South Canyon Fire in
1994. He said he wants to know how
the Forest Service intends to hold responsible people accountable.
Second Panel: Chief
Dale Bosworth said he began work with the Forest Service at the age of 17 when
he was hired as a firefighter. He
said both he and Jerry Williams had sons who are firefighters.
He said he deeply regretted the deaths of the firefighters
– and that the whole Forest Service family grieves for their loss.
He stated that he wanted to set the record straight with regard to a
perception that the Forest Service blames the victims for their deaths.
He said he is confident of the conclusion of the report that there were
management breakdowns. He said the firefighters were dedicated people and the fire
situation changed quickly. Mistakes
that were made long before entrapment reflect strategies that didn’t reflect
the fire situation. The fire was a
transition fire, a stage where fires are at their most dangerous.
He said there is an administration investigation underway that will look
at accountability and he said he reaffirmed his commitment to make safety first.
Fatigue, training, and accountability are among the priority items listed
in the action plan which will help with specific changes to be made.
Chairman Wyden asked what action would be taken regarding
knowledge of transition fires. Mr.
Williams said the interagency fire management group would be looking at fire
danger thresholds and strategies. Chairman
Wyden said he wanted briefings
every 60 days on progress regarding the action plan.
Senator Cantwell noted there were similarities between the
South Canyon Fire and the 30 Mile fire – communications breakdowns, lack of
management intervention, management’s inability to adapt to changing
conditions, management ignoring the 10 standard orders and 18 “Watch Out”
situations, and changing environmental factors. She asked if this showed that the Forest Service did not
learn the lessons of South Canyon. Chief
Bosworth said it is hard to show success, but failure is painfully obvious.
Mr. Williams said that firefighting is high risk and that he believed we
have adequate policies and procedures but the question is the adequacy of
performance expectations and accountability.
He added that the Forest Service fights 10,000 fires a year with 7,000
firefighters – policies and procedures have to be adhered to to prevent
fatalities. If they aren’t
adhered to – it’s a performance problem.
Senator Cantwell asked if training were adequate for 1st year
firefighters. Mr. Williams replied
that training is adequate but that training doesn’t stop at 32 hours –
on-the-job training and mentoring are also critical.
Senator Cantwell asked about how to reach zero tolerance violations.
Chief Bosworth said that “Safety First” has to have attention from
the top and has to occur before incidents happen – he added that a hard look
is being taken at all aspects of safety, not just firefighting.
Senator Cantwell asked who was responsible for the fatalities at the 30
Mile fire. Chief Bosworth said an
administrative investigation is underway.
Senator Cantwell asked why the Forest Service investigates
itself and wouldn’t a more objective view be better. Chief Bosworth said although he had confidence in the
outcomes of the 30 Mile investigation, it is helpful to have others outside the
Forest Service look at ways to deal with the performance issues.
Third Panel: Mr.
Schaenman described the study his company, Tri Data, Inc., conducted after the
South Canyon Fire at the request of the five agencies involved in firefighting.
The study was conducted by sociologists and psychologists and surveyed 1000
firefighters across the five agencies at all levels.
The goal was to identify the many facets of wildland firefighter safety
and recommend what to do about it. He
said the survey raised many issues – the need for qualified leaders,
accountability, experience, more visual and experiential training, clear
communications, crew cohesion, and attention to physical capabilities.
He recommended evaluation of outcomes of safety practices by collecting
data on near hits. He said many
positive steps have been taken, and that leadership for safety came from the
top. He said more action can still
be taken to improve safety on the fireline.
Mr. Gleason talked about his experience as a firefighter
from 1964 to 2001. He said we have
the 10 Standard Orders, 18 Watch Out situations, and LCES ( Lookouts,
Communication, Escape Routes, Safety Zones) – many firefighters see these as
guidelines, not rules. He said
firefighters don’t need more rules, they need experience in risk management.
He said it was important to retain experienced people and to have a
mentoring program. He said
firefighters are vulnerable during a transition fire in assessing whether to
engage or disengage. He said many
firefighters see the 10 standard orders and 18 “Watch Out” situations as
guidelines rather than rules. Mr.
Gleason said he thought mentoring entry level employees and using every
opportunity to give trainees on-the-job experience would help.
H said firefighter safety is determined by leadership – wildland
firefighting is manual labor in a highly complex and dynamic environment.
He welcomed Congressional oversight of firefighter safety.
Mr. Weaver spoke painfully of the loss of his son and
called for accountability by the Forest Service in the death of his son.
Senator Cantwell asked if his son had been trained in firefighting.
Mr. Weaver said Devin had received a week of training and had showed him
and his mother the list of safety rules. Mr.
Weaver said his son thought the Forest Service adhered to the rules but it
appears the Forest Service does not and his son is dead as a result.
Senator Cantwell asked Mr. Gleason if the conditions of the
fire would have been obvious to most people.
Mr. Gleason said the fire behavior indicators were there and the crew
supervisor should have seen them. He
said 1st year firefighters would not have had the experience to
realize the complexities of fire behavior and weather.
He said he thought the focus on orders and rules tends to skip the need
for risk management. He said all wildland fire management agencies need common
values, that it is okay to speak up and refuse assignements in unsafe
conditions. He said this is made
more difficult by the number of agencies (state, local, and federal) and parts
of the country where conditions vary. He
said he thought training needed to be continual and people needed to learn to
make decisions by watching experienced people.
Senator Cantwell asked Mr. Schaenman if Tri Data, Inc.’s
recommendations had been implemented. Mr.
Schaenman replied that many have been implemented and that changes can take
years to implement because they deal with human behavior and can be costly.
He said many resources are needed to improve mentoring, use simulations,
improve communications. He said most of all people need experience.
Mr. Williams said firefighting is a high risk, high
consequence business. He said that
the Forest Service safely and effectively controls over 10,000 wildfires every
year but even one accident is unacceptable.
Mr. Williams said we are proud of the “can do” spirit, but we
understand the critical importance of following established safe practices.
He said whenever crew leadership or supervisory controls or managerial
controls fail, narrow margins separate “can do” from “make do” and
“make do” from tragedy. He said
there is an administrative review underway to determine if a falldown in
leadership, supervision, or management contributed to the death of the
firefighters. Mr. Schaenman said he
recommends keeping track of near misses, as pilots do, so accidents can be
Senator Cantwell asked the panel what each would recommend regarding safety. Mr. Gleason recommended training and mentoring. Mr. Schaenman recommended more efforts in safety and training and asking the firefighters what they think. Mr. Weaver said he thought accountability to keeping safety rules was the most important thing.
For more information, contact: Chris Rose, Legislative Affairs. E-mail: email@example.com Telephone: (202) 205-1011.