|
RESPONSIBILITY & ACCOUNTABILITY ON THE CRAMER
INCIDENT,
THE CHANGING LITIGIOUS SCENE and AGENCY SUPPORT
From theysaid on 12/2/04.
By Misery Whip posted in response to a post by ME the day before.
(ME said on 12/1: I'm sure the investigators found the IC responsible in a
big way to press charges. Look at 30 mile. Was the IC prosecuted? no. Look at
Storm King, no action was taken even though they didn't relay weather info.
There had to be some direct fault on the IC's part in order to be held
responsible.)
Misery Whip replied:
Ah, ME, where to begin?
I don’t want to discourage you from posting on They Said. Everyone has a right
to air their opinions. And I’m sure your heart is in the right place.
But I got a feeling after reading your post that your fire experience might be a
little limited. I am guessing you are currently at about the crewboss level or
so? If you are, I hope you enjoy these years and the relatively light
responsibility of managing a single crew compared to the challenges of managing
hundreds of fire resources over a large piece of ground and sky.
Has your crew ever been strung out on a piece of line where you couldn’t see
them all at once? Whether you realized it or not, at that time you were in the
same boat as Alan Hackett at Cramer. You accepted responsibility for the actions
of people in your charge and trusted them to act safely while they were out of
your range of vision (or communications). You were relying on the
qualifications, training, and “common sense” (which really isn’t common at all)
of your personnel to keep them safe. And it sounds like you have been fortunate
so far. That is good. But here are a few truisms that you might want to consider
as you progress in your career.
Errors in judgment happen frequently on wildland fires. Even to the best and
smartest firefighters. If it hasn’t happened to you yet, it will sooner or
later. And to people around you.
Most of the time, when people make errors in judgment on wildland fires, the end
result is that NOTHING BAD HAPPENS! The snag misses, a well-placed tree prevents
the engine from rolling a thousand feet over a cliff, or the firefighter scoots
through a gap in the flaming front, and no one ever hears about it. A win for
the good guys (& gals)!
But occasionally, a series of unfortunate events and firefighters coincide. A
decision by someone, or some people, has an UNINTENTIONAL outcome. People are
badly injured or killed.
This is a critical point. Very rarely is an accident caused by a MALICIOUS
action of an IC or supervisor. Almost all fire accidents are the result of an
unfortunate alignment of circumstances. Somebody (or more than one body) has a
lapse of attention and misses the danger signals that are so easy to see after
an accident. People wind up in the wrong spot at the wrong time. Fire accidents
are extremely rare, but they are so catastrophic and traumatic that they
generate irrational responses.
Whether you (or the WO) notice it or not, the playing field has shifted
significantly since Thirtymile. Congresspersons Hastings and Cantwell put on a
good show for the families and press, demanding punishment for those involved.
They got it. And Thirtymile is not finished yet for some of those who were
involved.
And you should know that there were actually three side-by-side Cramer
investigations, by the Forest Service, OSHA, and the Office of Investigative
Services. The OIG apparently felt that making an example of Alan Hackett would
satisfy the expressed need of the families to see someone punished and would
also serve the needs of justice. When you are grieving for a perfect lost son or
daughter who has died on a wildfire, it is very hard to accept that they had a
big part to play in their own fate. IT IS THE RESPONSIBILITY OF EVERY
FIREFIGHTER TO MONITOR THEIR OWN SAFETY AND TO SPEAK UP, REGARDLESS OF THEIR
POSITION. Unfortunately, the two rappellers on the Cramer Fire helispot waited
too long before reacting to the fire below them, and they paid the ultimate
price.
So here comes my main point. Modern accident theory holds that accidents of the
Cramer type are largely organizational in nature. If personnel are not evaluated
and trained properly, if critical safety positions in an organization are
intentionally left unstaffed, if poorly skilled managers attempt to accomplish
what is beyond their abilities, accidents will happen with greater frequency.
Especially in an environment that has so many hazards. It is easy to find the
proximal causes of an accident, the trick is to recognize the systemic failures
that helped facilitate that accident. The blame trail can be followed all the
way to the top if one looks closely enough.
Don’t get me wrong. We DO need to investigate firefighter deaths. We DO need to
investigate near misses. We need to take all of those hard-earned lessons to
heart and make sure that no one falls prey to that particular set of
circumstances again. But if we create an environment where people are afraid to
admit mistakes that are the result of honest errors in human judgment, then we
have damaged our ability to learn from our mistakes, and our ability to prevent
similar incidents in the future.
Punishing people who were doing their best to serve the agency, who were trying
to do a good job, is having a DISASTROUS effect on our firefighting culture. ME,
your post suggests that there was an evil carelessness, a bad intent, or some
other dark force at work here. Have you considered that Alan Hackett might just
be a pretty decent guy, someone like you, who was just trying to cope with the
demands of his job? Have you considered that you might be standing in his boots
someday?
Here’s another important point. I am one of the few old farts left who started
fighting fire back in the sixties. I have never seen a time like this, where so
many good ICT3s & DIVS are questioning whether they can afford to accept the
criminal and civil liability that is becoming an unpleasant reality these days.
Many are opting out. Why risk everything when you can make just as much money
elsewhere? Who wants to go to jail for making an honest error in judgment? Why
take the chance of becoming a Judas goat for USFS senior managers who fail to
grasp what is happening to our best and brightest?
As I stated in a previous post, in these litigious times, wildland fire
supervisors need a Good Samaritan-type law. Paying for half of our liability
insurance is a cop-out and an empty gesture, and everyone who counts knows it.
Real leaders speak up in times of cultural uncertainty and doubt. THE CHIEF OF
THE UNITED STATES FOREST SERVICE, AND THE DIRECTOR OF FIRE AND AVIATION, NEED TO
STEP UP TO THE PLATE SOON AND STATE EMPHATICALLY THAT THEY, AND OTHER USFS
SENIOR FIRE MANAGERS, WILL UNEQUIVOCALLY SUPPORT EMPLOYEES WHO HAPPEN TO BE IN
POSITIONS OF RESPONSIBILITY WHEN TRAGIC INCIDENTS HAPPEN ON THEIR WATCH. If the
intent was noble, the defense should be automatic. Kowtowing to ignorant
politicians and grieving survivors should NEVER be allowed to interfere with
supporting an honorable employee in need of support.
I wonder if congresspersons Hastings and Cantwell, and the OIG prosecutors,
realize that their vocal demands to punish a few well-intentioned people are
actually making all of the remaining wildland firefighters less safe?
To the families and loved ones of firefighters who have died in the course of
duty, there will never be adequate consolation. Too many of my
aviator/firefighter friends have died during my career. I grieve for them all,
but the truth is, they all played a part in their final destinies.
And for the record, the woman in Colorado was prosecuted.
ME, I hope I wasn’t too harsh, good luck in your career.
Merry Christmas to all,
Misery Whip |
