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Evaluation of the Esperanza Investigation Report and the Forest Service Chief's Esperanza Action Plan

By Misery Whip, from TheySaid, 6/6/07

Cal Fire Esperanza Investigation Report 5/21/07 (links to report in parts)
Esperanza Action Plan (pdf file 23k small)

After poking through the Esperanza Investigation Report and seeing the Chief’s Esperanza Action Plan, I have some comments and questions.

To start with, I think the investigators missed some very key points and made some really bad assumptions.

We have ample evidence from this and many other burnovers that firefighters continue to be surprised by the suddenness and severity of these types of events. Why is that so? Is it just a temporary loss of situational awareness, a lapse in judgment by otherwise reliable employees, a “high risk-taking” culture, or is there something else going on?

How and why did the firefighter who triaged the octagon house two years earlier see the danger that these folks evidently did not? Is anyone else wondering why the octagon house was identified as a loser two years before the Esperanza Fire, yet an experienced engine supervisor and branch director both failed to realize the vulnerability of that same location and structure just before the burnover?

And I want to know more about why the investigators tagged Mark and the crew of E57 with rule breaking (pg 83: violation of orders, regulations, standard operating procedures). What order, regulations, or SOP did they break? Why doesn’t the report explain this point? If you’re going to say that someone did something wrong that led to a disaster of this magnitude, shouldn’t you be required to explain this statement?

I noticed the 10 & 18 analysis is conspicuously absent in this report. I, for one, applaud the decision to not include the 10 & 18 analysis because they are really not of much value except as a teaching tool and shouldn’t be part of our investigative process. Recognition Primed Decisionmaking (RPD) is what really drives firefighter decisions, not lists of very subjective guidelines. If the investigators felt that E57 broke one or more of the fire orders, such as “identify escape routes and safety zones,” they should just come out and say it.

The safety zone analysis on page 58 reveals just how conflicted and confused we are about identifying safety zones. The report calls the doublewide location a safety zone, yet acknowledges that personnel at that location had to conduct a critically timed burnout to withstand the approaching fire front and were forced to take refuge in vehicles. By our own definition, the doublewide was a deployment area, not a safety zone.

Let’s face it; we still don’t know how to define a safety zone or deployment area, and therefore don’t know how to teach firefighters how to recognize them. Although we teach firefighters that drainages and terrain features can channel convective gases and heat, we don’t spend a lot of time discussing this critical piece of fire knowledge, or train firefighters how to be cognizant of and avoid dangerous terrain/fuel combinations during critical burning conditions.

The Interagency Response Pocket Guide doesn’t even attempt to address this point when discussing calculations for safety zone size (for radiant heat only), except to say that “convective heat from wind and/or terrain influences will increase this distance requirement.” By how much? Under what conditions?

The Fireline Handbook calculation says a safety zone radius should be “four times the maximum flame height plus 50 square feet per firefighter” and “the Safety Zone diameter should be twice the value of the above formula.” But, “if the potential for the fire to burn completely around the Safety Zone exists, the diameter should be twice the values indicated above.” And then it says “keep in mind that these guidelines do not address convective energy.” Huh?

What I get from that description is that all safety zones should be round, and that if convective gases and heat are present these guidelines do not apply. Last time I checked, convective gases and heat are present on every fire, so apparently these supposed guidelines NEVER apply. In addition, how in the hell are you supposed to know beforehand what the maximum flame height will be on a given piece of ground? Isn’t sizing up a safety zone something you’re supposed to do well before the flames start reaching their maximum height?

To me, it is a cop-out to say that Mark and our comrades were careless or complacent about their own safety when we don’t have answers to even these basic questions.

Everything I have seen and heard and read about Esperanza points to two things: that Mark felt he and the crew of E57 could safely make a stand at the octagon house (pg 58: Engine 57 Captain communicated to others on the radio that he felt secure at his location), and that the conditions at that site quickly went from not-too-bad to deadly.

Folks, it isn’t radiant heat that suddenly changes from benign to deadly; its convective gases and heat. In case after case, the Cedar Fire, Thirtymile, and many others, it is the same story; big flames down slope/canyon, column/flames standing up and then lays over, firefighters caught unprepared by the sudden blast of heat, disorientated people reacting blindly in panic. That’s what being on the receiving end of convective gases and heat does to people.

Until our fire behavior people learn to calculate how convective gases and heat can “reach out and touch you” at distances far greater than present safety zone “radiant heat” guidelines are capable of predicting, and then turn that knowledge into a massive training program for all wildland firefighters to hammer home that a safety zone isn’t really a safety zone unless you can account for potential convective gas/heat impacts, we will continue to see events of this nature.

If you doubt that safety zone identification is a problem, ask any hotshot sup or foreman how often they have to “negotiate” with operations people about poorly located or insufficiently sized safety zones. If this wasn’t an issue, all firefighters should have an equal understanding of what constitutes a safety zone. We don’t.

OK. Now I want to address the Human Factors Analysis. I noticed the massive investigation team roster had all kinds of specialists, equipment specialists, operations specialists, a fire behavior analyst, even union reps. So where was the human behavior specialist? They performed a Human Factors Analysis, surely they had guidance from someone with a high level of expertise in this area.

Or maybe not.

On page 80, the HFA failed to give fatigue any value as a contributor to this accident (late-night or early-morning operations, circadian disruption). I would be curious to know how they arrived at this conclusion, given that the firefighters were rousted out of bed a few hours after midnight and the accident occurred just after daybreak. I think most behavioral scientists would find it is entirely likely that the disruption of their sleep cycle had some negative effects on the mental acuity of crew of E57.

On page 81, the HFA said that using improper procedures, ill-structured decisions, and failure to perform required procedures were contributors. If you buy that we have a clearly and mutually understood system for identifying safety zones, this might be correct. I do not. I felt that “inadequate essential training for specific tasks” (ie training to identify safety zones that requires firefighters to calculate potential dangerous effects of convective gases/heat) of and “failure in problem solving” (failure to predict deadly conditions at the octagon house after fire became established on the slope below them) were more pertinent to explaining why Mark and company did not anticipate the sudden blast of heat that overwhelmed the firefighters at the octagon house.

On page 82, the HFA says that intentional and unintentional deviations from procedures were contributors. Without knowing which procedures the investigators were referring to, this is hard to judge. But they failed to check “inadequate essential training for specific tasks” (ie how to identify safety zones where firefighters can safely withstand potential convective gas/heat impacts), which I feel is very applicable.

Page 83 bothers me a lot. The references to high-risk behavior, complacency, imprudence, deviation from procedures seem to me to be misplaced. I think the investigators misinterpreted Mark and crew’s failure to predict the eventual outcome as a failure of character. I think it is an organizational failure. That is why I would have checked “inadequate training” as it applies to this event.

The rest of the HFA is more of the same, vague statements about safety attitude, safety culture, etc. One point with which I heartily agree is that our “organization lacks adequate process or procedures for operational risk management.” Like a training program that trains firefighters to identify safety zones without loopholes such as “for radiant heat only.”

I hope our Chief will re-evaluate the proposed Esperanza Action Plan. Improved mapping of non-defensible structures and abandoning structure protection will still leave wildland firefighters vulnerable to the same problem that killed the firefighters at Mann Gulch and has factored into every wildland fire burnover since. The real problem we should be talking about is threat recognition, and how to improve the ability of all firefighters to recognize when they can expect life-threatening fire conditions on any piece of fireground, under any weather and/or fuel conditions.

And whoever thought up the “It’s cool to be safe” slogan that keeps appearing on WO stationary ought to be spanked. For one, safety slogans are pretty much useless, and this one is an affront to the memory of the crew of E57. Until someone can prove to me otherwise, I will continue to believe that the crew of Engine 57 was probably just like the rest of us, doing the best they could, with the tools and knowledge they had, and that the Esperanza investigators have done them a disservice by suggesting they were complacent about safety.

Misery Whip

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