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Hindsight Bias and Conflicting Witness Statements in the 30 Mile Tragedy
December 31, 2006
Misery Whip

Misery Whip's analysis below rebuts the contention that Ellreese was lying:

Don’t look now, but your hindsight bias is showing. You seem to have fallen for Agent Parker’s still very UNPROVEN assertions that Ellreese lied about his actions at Thirtymile, so therefore was guilty of trying to hide his own mistakes that contributed to the fatalities. I think there is a far more plausible and less sinister answer as to why there are conflicts among the Thirtymile firefighters witness statements.

You could start by putting events in their proper context.

Don’t forget that NWR Crew 6 crewpersons had all worked the previous day, had maybe a couple of hours of rest, then traveled the rest of the night and worked all day on a tough fire. The investigation report equated their sleep-deprived condition to a .10 blood alcohol level, or legally drunk. How reliable do you think ANY of the firefighters statements are given that what they were seeing and hearing was filtered through their handicapped mental state?

You (and Agent Parker) ought to know better than to expect everyone’s witness statements to exactly line up following a traumatic event such as this. I actually find it remarkable that there are so many statements within the criminal complaint that corroborate Ellreese’s version of events.

Witness statements acknowledge that Ellreese yelled and gestured at one firefighter to come down, that Ellreese expressed to other firefighters that the road was probably the best place to be, that Ellreese told firefighters to get shelters out and to “cover your buddies,” etc.

The criminal complaint cherrypicked the evidence against Ellreese to attempt to portray that he had a careless indifference to safety. When viewed in totality, the Thirtymile Fire Investigation Report reveals that significant management failures outside of Ellreese’s control also contributed to the overall outcome. The complaint makes it seem as though only Ellreese made errors in judgment. And there is a large difference between being carelessly indifferent to the safety of others and making honest errors in judgment.

The Thirty Mile abatement plan is a laundry list of admitted management failures. For instance, work-rest guidelines were revised because of Thirtymile. Working at the time under the old rules, Ellreese and crew were attempting to make important decisions in a sleep-deprived state that would have severely impaired their abilities to maintain good situational awareness and make good decisions.

Another post Thirtymile management change is the restriction that personnel cannot simultaneously be a crew boss and IC. That sort of “duty shifting” of roles was common before Thirtymile, and was found to be a contributing factor in this case. The fact that he was essentially pressured into accepting simultaneous roles as ICT3/CRWB/trainer cannot be construed as Ellreese’s failure, this was a management failure.

The complaint reveals a blatant hindsight bias in its interpretation of events. The “Lessons from the Thirtymile Fire” training program was created in response to the Thirtymile Abatement Plan’s mandate to share lessons learned from this incident. Entrapment Avoidance training and entrapment reaction drills only came about after Thirtymile. Again, these programs were developed after recognition that this area was lacking before Thirtymile.

Post-Thirtymile Fireline Leadership training and post-Cramer ICT3 simulation evaluations are additional belated acknowledgements that agencies had also previously neglected teaching basic leadership and communication concepts. Ellreese and company did not have the benefit of hindsight and leadership training/evaluation specifically designed to help improve leadership and communications during stressful circumstances like entrapments.

The complaint undercuts its own case throughout with statements meant to bolster the prosecution’s interpretation that Ellreese lied to cover his failings. I saw many indications that Ellreese did attempt to communicate with the people on the rocks and expressed concern that everyone would be better off on the road. Ellreese is a very soft spoken individual and does not have a forceful personality. I very much believe that in his own mind, he feels he did these things.

Remember, this was an extremely sleep-deprived person who was dealing with a troublesome fire and some strong-willed individuals in his charge. The other crewmembers were also sleep deprived and distracted by fear and side-events, so their attention span and memory of what actually transpired is also suspect. And even though the firefighters had been watching the fire advance up canyon toward them, everyone at the upper site was surprised by the suddenness and severity of the event’s onslaught.

Errors in judgment should not be construed as indicators of carelessness or bad character. When you take into account that many of the key players were operating under a severe sleep deficit and experiencing extreme stress, it is not surprising that errors were made and that people have different recollections of specific events.

At the time of the Thirtymile Fire, no training or method existed for helping firefighters determine the size and location of safety zones in various fuel and terrain conditions, and which locations might be especially vulnerable to firewhirls and convective heat and/or gases. The guidelines in the Interagency Response Pocket Guide are for radiant heat only. How can Ellreese be faulted for not being able to predict something that fire behavior experts still are unable to define? The effects and range of convective gases and heat in relation to determining safety zone size and location is still largely guesswork based on experience. And as we saw again this past summer, firewhirls can emerge from nowhere and rapidly cross open ground independently from the main fire.

Although the Interagency Response Pocket Guide contains safety zone size specifications for protection from radiant heat, guidelines for protection from convective gas/heat and firewhirls still do not exist today. The firefighters at Thirtymile undoubtedly experienced an unusual fire phenomena that is still not completely understood.

After the entrapment, Ellreese’s biggest error was underestimating how severely the down canyon crownfire would impact their location, and consequently failing to make deployment preparations. Once the situation became deadly, there was really no opportunity for Ellreese to direct the actions of firefighters and civilians. People simply reacted wherever they were when the heat wave struck and deployed.

I still have an unforgettable memory from my first visit to the Thirtymile fatality site. As I looked around, I realized that had I been in their place, I very likely would have determined that anywhere in the general van/road/rock scree area would be survivable without a shelter. And so I very well might have made the same judgment as Ellreese, that the fire would not heavily impact them and so would also have been caught unprepared.

I wouldn’t make the same choice today if I was caught in a similar situation. Based on what I learned from Thirtymile, I would prep for the worst and get everyone ready for a shelter deployment. But I have the benefit of hindsight.

Misery Whip

aerial photo of Thirtymile fatality site
more photos:

Also good is this Lessons Learned training from MTDC: Ab.

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