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MORE RESPONSIBILITY & ACCOUNTABILITY ON THE CRAMER
INCIDENT,
THE CHANGING LITIGIOUS SCENE and AGENCY SUPPORT
From theysaid on 12/13/04.
By Misery Whip
BB, Sorry for taking so long to reply, I just returned from a road
trip. In reference to my 12/2 post, thanks, and, yes, feel free to share
it.
To Original Ab & everyone else who liked my 12/2 post,
Thanks, it needed to be said. Obviously, I’m not the only one who feels
this way.
To VFD Cap’n,
I have read and admired a number of your posts on this website. In
reference to your 12/3 post on They Said, I don’t recall anyone arguing
on this site recently that the skills and training of people in charge
of fatality incidents shouldn’t be re-evaluated, or that fatality
incident supervisors shouldn’t be re-assigned to other duties if they
make serious errors in judgment.
What I object to is the implication that Alan Hackett is a bad person
because this bad thing happened on his watch. Somebody died, ergo
someone in charge was bad and must be punished. Is it right to debase
and humiliate a public servant who was just attempting to cope with a
bad situation to the best of his abilities? Should he have to cop a plea
and lose everything he has worked his entire life for or face jail time?
I don’t think so.
I don’t know Alan Hackett, but I do know some of the surviving
supervisors and firefighters from South Canyon, Thirtymile, & Cramer.
They are mostly good people who had good intentions that went awry. Many
of them are also post-traumatic stress victims, and whatever parts they
played in their respective tragedies, deserve compassion for having to
view firsthand the results of Good Intentions Gone Wrong.
INTENT is the real issue at hand here.
Yellowjacket, In reference to your 12/3 post on They Said, I know more
about the Cramer Fire investigation, South Canyon & Thirtymile too, than
you could possibly imagine. Since accountability seems to be the axe you
are grinding, how far do you think accountability should extend for
Cramer? How many others should we fire and turn into criminals? Do you
think that fear of punishment will make the rest of us more diligent and
therefore safer?
So as long as we’re after accountability, how about firing the
Salmon-Challis forest supervisor (oh, wait, he resigned), the rappel
spotter, the dispatchers, the pilots (can’t fire them, they’re
contractors), the ATGS, the district ranger, (can’t blame the FMO, there
wasn’t one), the fire staff? Why stop there? How about whoever signed
off Alan Hackett as an ICT3, and for that matter anyone who signed off
on any of his taskbooks? And who was responsible for training Shane and
Jeff, and for signing them off as rappellers and fallers?
Yes, we’ll all feel better if we punish all of these people some more.
As if they hadn’t punished themselves enough already.
And then, let’s humiliate them some more by publishing their punishments
as a proclamation and warning to everyone else to BE PERFECT, OR YOU TOO
WILL BE PUNISHED!
Do you not see how flawed this line of reasoning is?
Did you ever stop to think that maybe your conclusions are incorrect on
this issue, and that what you interpret as “whining” and being
“brainwashed by the government” is really a humane and accurate
perspective?
Maybe it would help if you understood what some of today’s leading
experts on accidents and risk management have to say about Cramer-type
incidents. In “Managing the Risks of Organizational Accidents” by James
Reason, the author describes why we live in the age of the
organizational accident:
“There are two kinds of accidents: those that happen to individuals and
those that happen to organizations.”
“Organizational accidents have
multiple causes involving many people
operating at different levels of their respective companies.”
Organizational accidents do not happen in a vacuum; they are spawned by
organizations performing complex activities in technology laden
environments. Reason’s book shows why it is myopic and morally wrong to
only look at the proximal causes of an accident such as Cramer without
looking at the entire system and organization that sponsored the
activity that led to the accident. Cramer is really a classic
organizational accident.
I highly recommend that you obtain and read a book called “Beyond
Aviation Human Factors/Safety in High Technology Systems” by authors
Daniel Maurino, James Reason, Neil Johnston, and Rob Lee. Collectively,
these people are among the most highly regarded in the world today in
the related fields of human factors, risk management and accident
analysis.
If you don’t want to read the whole book, at least read chapter 3,
“Pathogens in the Snow: The Crash of Flight 1363”. It is the story of a
watershed event in accident investigation history. The chapter describes
an Air Ontario crash in 1989 that killed 21 passengers, the captain, and
two other crewmembers. In brief, the Canadian government commissioned a
special inquiry to determine why an experienced pilot with a history of
being conservative would willingly take off into dreadful flying
conditions with wings loaded with snow and ice.
The real hero of the “Pathogens in the Snow” story is The Honourable Mr.
Justice Virgil P. Moshansky, who was appointed Commissioner of the
Commission of Inquiry to look into the incident. The authors state what
took place next:
“Without hesitation, Mr. Justice Moshansky discarded
what was as obvious as inconsequential-the notion of pilot error- and
over a period of 20 months literally tore apart the Canadian aviation
system, diligently advised by a multi-disciplinary team of
investigators, safety officials, Human Factors practitioners and
researchers, pilots, engineers, and regulators, trying to find the
answers behind the flight crew’s decision to take off”.
The landmark four volume, 1700 plus page report that was eventually
produced is known as the Final Report of the Commission of Inquiry into
the Air Ontario Crash at Dryden, Ontario, sometimes shortened to just
The Dryden Report. The authors hail this report as “an accomplished
exercise in accident investigation and prevention from the systemic as
well as from the organizational perspective”.
Watcher is exactly correct when he/she states that Cramer was a
manifestation of a systemic problem.
And, Yellowjacket, if you don’t want to read the whole chapter, at least
read the paragraph on page 71 that states “flawed organizational
processes and latent failures are the source of most unsafe acts
committed by operational personnel”.
Let’s look at that statement again. “Flawed organizational processes and
latent failures are the source of most unsafe acts committed by
operational personnel”.
What the hell does that mean?
It means that the real world is probably far more complex than you may
presently understand. And it doesn’t sound anything at all like “I
INTEND go out and do a half-assed job of managing the Cramer Fire today
and I don’t care if someone gets killed”, which seems to be what you and
some others are implying about Alan Hackett’s mindset on that fateful
day.
Often missing from the Cramer discussion are recent advances in our
understanding of human factors. As we approach the tenth anniversary of
the Wildland Firefighter Human Factors Workshop, it is worth assessing
just what we have learned about training firefighters over the past
decade.
One important core concept that is just starting to be better understood
by the wildland firefighting community is Recognition Primed Decisionmaking (RPD). Simply put, RPD is what behavioral scientists say
is at the root of how incident commanders make decisions in the complex
wildland fire environment. You compare your present situation to a
similar situation or situations that you have experienced previously,
then make your decision based on your memory of the outcome(s) of the
previous experience(s).
RPD is why the grizzled old hotshot supe and a rookie crewmember see a
completely different mental picture of the fire. The supe may not be
able to hike as fast as the rookie these days, but the superior
experience and “RPD memory bank” of the supe usually enables him/her to
see potential threats, anticipate what might go wrong, and make sound
safety decisions in hazardous situations. In the course of a day, the
rookie is probably blissfully unaware of dozens of potential threats to
his/her safety that the supe instantly detects and mitigates or avoids.
It’s that simple. It’s why sandtable exercises are such a valuable and
effective learning tool. Why not make the mistakes in training instead
of real life where the results may be catastrophic?
Unfortunately, sandtable exercises and simulators can only do so much
for training firefighters. At some point, you have to go out and grapple
with the real thing, and the wildland fire environment is filled with
hazards. Prescribed fire is really the only other opportunity that
wildland firefighters have to learn how to “play with fire” in a
somewhat controlled environment, although control of a prescribed burn
can sometimes turn out to have been an illusion.
As long as human beings plan to continue to light and fight wildland
fire, they will continue to come into contact with hazardous situations.
If the RPD memory banks of wildland firefighters are not filled with the
kinds of experiences that will help them recognize potential hazards, or
if they are distracted from maintaining Situational Awareness at
junctions of critical events, accidents and fatalities will continue to
happen.
The truly revolutionary Fireline Leadership program developed by Lark
McDonald, Jim Cook, and others is the first wildland fire training
program to really identify what Situational Awareness is, and how
critical it is to firefighter safety. Firefighters are now being trained
to recognize that SA is not a static process. SA needs to be
re-evaluated as time passes, conditions change, or the firefighter’s
location changes.
Fireline Leadership also teaches that SA can be elusive, that it is not
possible to maintain a constant state of perfect SA, and that
distractions can instantly change the focus from SA to something else.
This is what bothers me about Alan Hackett’s current predicament. My
assessment is that Alan, who was trying to manage several aircraft and
several other fires in addition to being the IC of Cramer, was probably
overtasked, likely facing multiple distractions because of that, and
made some errors in judgment. No doubt about it. But if you have never
been in that kind of pressure cooker before, you should not be too quick
to presume that you would do any better. Personally, I seriously doubt
that his INTENT was to harm anyone.
Why isn’t anyone outraged that a forest FMO position had INTENTIONALLY
been left unstaffed on a fire-prone forest with a history of dangerous
fires? Why isn’t anyone outraged that a loyal employee was INTENTIONALLY
left floundering trying to do two critical jobs at once, was
consequently unable to do either job well, and was left holding the bag
for the organization’s failures? Why isn’t anyone outraged that we have
a system that acknowledges emerging Type 3 fires are the most dangerous
and difficult fires to manage, yet we still INTENTIONALLY cobble
together short Type 3 “teams” on the spot to manage the damn things? Why
isn’t anyone outraged that a large part of our firefighting workforce is
INTENTIONALLY composed of agency and contract temporary employees, who
are sometimes poorly trained, and have few rights and fewer benefits?
Regardless of any mistakes that Alan Hackett made, including the lack of
posted lookouts on the fire, they should not have been fatal mistakes
for Shane and Jeff if they had been properly trained to recognize the
danger of their situation and had been properly trained to react
accordingly. Or maybe they were properly trained but just got distracted
and lost SA at the critical moment, too focused on the helicopter to
have an alternate plan. I will always wonder what they were thinking in
their last minutes. The Cove Creek helibase radio operator even prompted
them to go to the safety zone minutes before the burnover. They knew the
fire was close below them, why didn’t they just pull out a fusee, burn
off a survival area, and walk into it?
Had no one ever told them, or had they never observed personally, that
Salmon River fires grow in spurts by sending chunks of burning material
rolling down the steep slopes, then a little while later the fire
started by the burning rollers comes roaring up to the ridgetop? That
you always maintain good SA and keep a survival fusee handy on Salmon
River fires? That under extreme burning conditions fire can rip through
scabby grass and brush faster than you can run?
In all of the discussion about Cramer, many people seem to be missing
this one very important point. In the sprawling and ever-changing
wildland fire environment, safety is ultimately very local in scope and
dependent on the abilities of individuals or small groups of
firefighters to recognize and avoid local hazards. How does an IC
“control” resources and guarantee a safe assignment on a large, rapidly
evolving incident? You don’t. You can’t, because it is not possible to
be everywhere at once.
My last Type 3 IC assignment was an uncontrolled 90,000+ acre WUI fire,
it took me 45 minutes to fly around the perimeter of the damn thing in a
helicopter! If anyone thinks that I had “control” at any given moment in
time (beyond AM briefing) over any of the hundreds of firefighters who
were scattered around this incident, or “control“of the aircraft over my
fire at any given moment, then you are deluded.
I did what all ICs do on large fires: I did my best to assess the fire
situation and the personnel assigned to me, I made assignments based on
my assessment of the situation, then I kept one ear on the radio and
cell phone for signs of problems. I monitored assignments and how the
fire and firefighting efforts were evolving to the degree I was able.
And then I crossed my fingers and hoped that no one on my fire had a
lapse in Situational Awareness and got themselves or someone else
killed.
In a perfect world, every Incident Commander would be able to trust that
every firefighter on an incident, including firefighters from other
agencies and contract/AD/emergency hire firefighters, all have had the
correct type of training and experience that will allow them to detect
and avoid immediate hazards in whatever situations they encounter.
In this Shangri-la mythical fire world, an IC can also presume that
every firefighter has perfect Situational Awareness at all times,
communicates flawlessly, and always makes the right decision. Is this
realistic? Of course not!
So, is there really no chance of making wildland firefighting completely
accident free? It may be, in fact, impossible to completely eliminate
hazards to firefighters short of discontinuing fighting wildland fires
altogether. Behavioral scientists have coined the term “error
management” as an acknowledgement that human beings will always be prone
to errors for a number of reasons.
The real truth is that people will never be able to be completely free
from making errors in judgment. No matter how good training gets, no
matter the experience levels of our fire supervisors at “the tip of the
spear”, there will always be situations where someone, or several
people, will fail to note or react correctly to a hazardous situation,
and someone will pay a price. The sooner we get used to this notion and
heed what it means, the better off we will be.
I hope the WO is listening to what Dick Mangan said in his 12/3 post
about the post-Cramer events being the biggest thing to impact wildland
firefighting since the 1910 fires. It just may turn out to be just that.
But there are reasons to be hopeful in all of this mess. In 1995, Ted
Putnam (former USFS, now retired) helped facilitate the first Wildland
Firefighter Human Factors Workshop, which is regarded by some as a
landmark event and the beginning of a paradigm shift in wildland
firefighting. Among other distinguished participants in the workshop,
Dr. Karl Weick from the University of Michigan presented an excellent
paper on South Canyon entitled “South Canyon Revisited: Lessons from
High Reliability Organizations”.
The book that Dr. Weick co-authored with Kathleen M Sutcliffe (2001),
titled “Managing the Unexpected: Assuring High Performance in an Age of
Complexity” is now becoming popular in certain circles in the WO and
being held up as a model of where we should go to find help to fix our
presently dysfunctional wildland fire culture.
Managing the Unexpected describes High Reliability Organizations, which
generally are defined as communities of people engaged in complex and
potentially dangerous activities like managing aircraft carriers and
nuclear power plants. By following certain core precepts, HROs manage to
have less than their fair share of accidents. Dr. Weick even describes
wildland firefighting as an HRO style organization, but I am skeptical
that we really deserve that title.
At the heart of the HRO concept is the idea of developing a safety
culture. And in order to have a high-functioning safety culture, it is
first necessary to foster a reporting culture and an environment where
it is not only not socially stigmatizing but socially acceptable and
positive to report and share personal errors in judgment. In an HRO,
under some circumstances, persons who self-report certain errors in
judgment are even rewarded!
So here we are, in 2004, hanging Alan Hackett for the crimes of Trying
To Wear Too Many Hats While Managing A Type Three Incident and Making
Errors In Judgment. What kind of effect do you think this is going to
have on our reporting culture?
If you accept that it is impossible to eliminate errors in judgment, how
can you blame Alan Hackett for making errors in judgment, or for failing
to anticipate that two firefighters on an isolated portion of the
incident he was managing would not correctly interpret what was about to
happen to them and would also make errors in judgment? Does anyone not
understand that Alan Hackett would probably give anything to go back in
time and change what happened at Cramer?
I hope our new Director of Fire and Aviation, Tom Harbour, has the same
enthusiasm for Managing the Unexpected that Jerry Williams had, and that
he can find a reasonable solution to this debacle. If not, next summer
is going to be a train wreck. I hope he figures out very soon that if he
doesn’t support employees in need of defense like Alan Hackett
regardless of what the newspapers, congresspersons, lawyers, and
families say, the problem will solve itself. There won’t be any problem
with Type 3 ICs because you won’t be able to find anyone who is willing
to be a Type 3 IC any more.
Ab, Sorry about the length of this beast but there has been a lot of
discussion lately about Cramer issues that I felt some people were
misinterpreting.
Merry Christmas to everyone,
Misery Whip
Misery Whip's previous post from
12/2/04 and following post from
12/16/04. |
