|
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
|
