Findings From the Wildland Firefighters Human Factors Workshop

Workshop Overview

The Start

From the beginning, workshop emphasis was on people, not fire. It was about peopling fires, not fire suppression. With the former, we organize trained people to perform a task safely and efficiently, and the relevant task is fire suppression. In the latter, we suppress fires using people. Historically, this has led to overemphasizing the fire and de-emphasizing and devaluing the firefighter. We have spent millions on fire research but little on firefighter research. We have many fire researchers. We have no firefighter researchers.

On July 6, 1994, we lost 14 firefighters on Storm King Mountain. The investigation of these fatalities clearly showed both psychological and organizational failures. How did these failures come about? What can be done to bring the primary focus back to valuing people? Trees regrow, houses can be rebuilt, but the loss of a life is forever. What has unfolded in the aftermath is a reaffirmation that people are first. All else is secondary in wildland firefighting.

Mark Linane (left), Bill Bradshaw (center), and
Buck Latapie (right) discuss the Mann Gulch strategies
from a "human factors" standpoint.

The 1994 fire season in which 34 people died was the catalyst that brought together firefighters, safety managers, psychologists, and sociologists for the workshop. Together we discussed the human side of fighting fires. We examined firefighters, firefighter crews, fire management, fire culture, and fire communities with the goal of enhancing the firefighter amid a more highly resilient organization.

The workshop began with four keynote speakers who discussed new concepts to give firefighters a look into ways to improve themselves, their interactions, and the entire wildland fire community. Kurt Braun discussed the role human behavior plays in safety and injury, with emphasis on risky behaviors common in the wildland fire environment and how to change to reduce those risks. Gary Klein showed how experienced firefighters used recognition-primed decision (RPD) strategies and how experience is crucial for quick, effective decisions in a fast-changing, risky environment. David Hart discussed cultural attitudes that can enhance or hinder firefighter safety and effectiveness and how training can make individuals and crews more resilient to failures. Finally, Karl Weick introduced insights from high reliability organizations that help improve communication, leadership, group structure, and sense making, which in turn decrease stress and the chance of catastrophic errors.

That afternoon and the following day, the workshop experts discussed firefighters, firefighting, and the fireground, and explored the interconnections, emphasizing what was working or what was not. Possible solutions were discussed. The third day participants took the discussion into the field with a trip to Mann Gulch. The fire scenario was reviewed where it happened, including how people interacted with each other, the decisions that were made, and how events unfolded in an increasingly risky, changing environment. Insights not found in original reports were put forth to explain how and why 13 firefighters died on the Mann Gulch Fire. These new insights from a psychological perspective show that analysis and conclusions depend upon the experiential bias of the investigator. The Mann Gulch experience invigorated the participants. The final two days were spent exploring solutions and developing both long-term and short-term recommendations.

The goal of the workshop was not to come up with quick solutions. Rather it was to explore the human issues of wildland firefighting and recommend to fire management corrective actions that would have lasting effects. As with all explorations of human behaviors, the complexity and variety of issues was apparent. But it became clear that a great deal of relevant knowledge already exists that other organizations have institutionalized to reduce risk and improve safety. Before we can use this knowledge in the wildfire context, we must establish baselines for relevant behaviors. Without such benchmarks, we would have no precise way to measure change once corrective changes are implemented.

It was quickly apparent in our discussions that fire agencies are not routinely collecting and analyzing data that would give us a good idea about the current behaviors of wildland firefighters. We don't even collect crucial near-miss information on the wide variety of risks inherent in firefighting. We only do a good job of recording fatalities, Ensely (1995), but this strongly biases our view of normal, routine behaviors. Such a narrow focus precludes warning trends that would become apparent in an analysis of near-miss situations. Therefore, workshop output depended on the experience level and ability to recall relevant information gathered in workshop discussions, but for purposes of future discussion and corrective actions, the information is grouped into the following three main areas.

• A broad vision of how to reorganize wildland firefighting based on insights from High Reliability Organizations (HRO's).
  
  
• A specific reorganization of Incident Management Teams and fire crews along crew resource management (CRM) lines.
  
  
• Better assessment and feedback for all wildland firefighting activities.

High Reliability Organizations: A Vision for Fire Reorganization

The wildland fire community should reorganize using High Reliability Organizations (HRO's) as a model. Examples of HRO's are nuclear power plants and aircraft carriers.

Characteristics of HRO's include (Rochlin 1993):

• The activity or service is inherently complex in that tasks are numerous, differentiated and interdependent.
  
  
• The activity or service meets certain social demands that require performance at the highest level of service obtainable within present safety requirements, with both a desire for an even higher level of activity and a penalty (explicit or implicit) if service slackens.
  
  
• The activity or service contains inherent technological hazards in case of error or failure that are manifold, varied, highly consequential, and relatively time-urgent, requiring constant, flexible, technology-intrusive management to provide an acceptable level of safety to operators, other personnel, and/or the public.

Although fighting wildfires is not as technologically complex as classic HRO activities, the management issues are similar, particularly in the urban interface and prescribed fire arenas.

The yardsticks to determine a wildland fire HRO's reliability and effectiveness could include the following (Creed and others 1993):

• From whose perspective is effectiveness or ineffectiveness judged?
  • Management
  • OSHA
  • Firefighter
  • Public
  • Politicians
  • Media
    
    
• On what domain of activity is the analysis focused?
  • Safety
  • Training
  • Acres burned
  • Cause and effect
  • Houses saved
  • Decision making
  • Accidents
  • Sense making
  • Near misses
  • Attitudes
    
    
• What level of analysis is being used?
  • Individual behavior
  • Baseline
  • Crew behavior
  • Culture
  • Longitudinal
    
    
• What is the purpose for assessing effectiveness?
  • Error reduction
  • Promoting safety
  • Determining causal relationships
    
    
• What time frame is being employed?
  • Short term
  • Long term
    
    
• What types of data are being used for evaluating effectiveness?
  • Error rates
  • Compliance
  • Incidents
  • Safety checks
  • Accidents
    
    
• What is the referent against which effectiveness is being judged?
  • Agency standards
  • OSHA standards
  • Similar organizations

In analyzing the safety culture in HRO's, the factors and their contributory weights were (Koch 1993):

Factor	Percent explained by factor
Accountability/Responsibility	23.2
Adaptiveness/Responsiveness	16.3
Openness/Cooperation	15.4
Hazard awareness	14.2
Inquisitiveness/Search for detail	13.2
Role clarity	9.7
Maturity	8.0
	100.0

 

While HRO's depend more on technological controls than wildland fire agencies, the process of looking at their organizational structure is relevant.

Using the Crew Resource Management Model in Fire

Crew resource management (CRM) focuses on behaviors of crews. Adoption of CRM training and cultural changes has dramatically reduced near misses and accidents in the airline industry. Most of the organizational and interactive behaviors that are part of CRM are relevant to the entire wildland fire community.

CRM focuses on honing seven skills: situational awareness, mission analysis, decision making, communication, leadership, adaptability, and assertiveness (Prince and others 1993; Frantz and others 1990).

These seven skills can be divided into taskwork skills and teamwork skills. Taskwork skills include: situational awareness, mission analysis, and decision making.

• Situational awareness is the perception of what the fire is doing and what you are doing in relation to the fire and your goals. It involves an awareness of fire behavior and terrain and the ability to predict where the fire and you will be in the future. This skill depends both on individual perception and sharing it with the rest of the team.
  
  
• Mission analysis involves organizing and planning. It involves breaking the mission down into subtasks, assigning priorities to these subtasks, and monitoring completion until the mission is over. It begins with an organized briefing and clarifies important issues related to the mission.
  
  
• Decision making involves deciding which decision model is most appropriate for firefighters, such as Recognition-Primed Decision making. It also involves training firefighters in decision making and using it under simulated stressful conditions. Decision making includes collecting, integrating, and implementing information for the most effective task performance.

Teamwork skills include: communication, leadership, adaptability, and assertiveness. Communication and leadership involve at least two people,

• Effective communication primarily depends upon the clarity, quality, and timeliness of the message. Miscommunication has been a causal factor in many accidents.
  
  
• Leadership skills include delegating tasks, providing feedback, promoting crew motivation and cohesion—all in an atmosphere that fosters openness by allowing crew members to present alternative views without fear of criticism. The most effective leaders take an active role in involving the entire crew in a team effort, discussing interactions required for the tasks, and clarifying norms and roles.
  
  
• Adaptability refers to the ability to change behaviors during a fire to react to changing conditions and to other crew members. It refers to trying new behaviors when old behaviors are no longer effective.
  
  
• Assertiveness is necessary to help individuals who may feel intimidated by a person's position or fire experience. It assures that everyone's special knowledge will become group knowledge.

Communication and leadership involve at least two people, whereas adaptability and assertiveness are more individual characteristics.

Components of the CRM Taskwork Skills as They Relate to Fire (Prince and Salas 1993)

Situational Awareness—

• Identify problems/potential problems
• Recognize the need for action
• Attempt to determine why discrepancies exist with information before proceeding
• Provide information in advance
• Demonstrate ongoing awareness of fire assignment status
• Demonstrate awareness of your own task performance
• Note deviations

Mission Analysis—

• Define tasks based on fire assignment
• Structure strategies, tactics, and objectives
• Identify potential impact of unplanned events on a fire
• Critique existing plans
• Devise contingency plans
• Question/seek information, data, and ideas related to fire plan

Decision making—

• Cross-check information sources
• Anticipate consequences of decisions
• Use data to generate alternatives
• Gather pertinent data before making a decision
• Evaluate information and assess resources
• Identify alternatives and contingencies
• Provide rationale for decision

Components of the CRM Teamwork Skills as They Relate to Fire

Communication—

• Use standard terminology
• Provide information as required
• Provide information when asked
• Ask for clarification of a communication
• Make no response (negative)
• Acknowledge communication (okay)
• Repeat information
• Reply with a question or comment
• Use nonverbal communication appropriately

Leadership—

• Determine tasks to be assigned
• Establish procedures to monitor and assess the crew
• Inform the crew members of fire assignment progress
• Verbalize plans
• Discuss ways to improve performance
• Ask for input; discuss problems
• Tell crew members what to do
• Reallocate work in a dynamic situation
• Focus crew attention to task
• Provide a legitimate avenue for dissent
• Provide feedback to crew on performance

Adaptability/flexibility—

• Alter fire plans to meet situation demands
• Alter behavior to meet situation demands
• Accept constructive criticism and help
• Step in and help other crew members
• Be receptive to others' ideas

Assertiveness—

• Advocate a specific course of action
• State opinions on decisions and procedures even to higher-ranking crew member
• Ask questions when uncertain
• Make suggestions
• Raise questions about procedures

This enumeration of examples under each of the seven CRM skills clearly shows the similarity in requirements for success between the cockpit and the fireline. Both place a premium on individuals operating as close-knit teams. Because of this similarity, CRM research data and training courses can be readily tailored to wildland firefighting.

Assessment and Feedback

Assessment and feedback are essential for effective individual, team, and agency success. That is why assessment and feedback are such an important part of both HRO's and CRM. But within the Federal wildland fire establishment, assessment and feedback are used so seldom that the workshop singled them out as the third area of major concern.

Throughout the workshop it was evident firefighters are being sent conflicting messages from a variety of sources: political oversight, the agency, the public, and the fire organization. Most firefighters feel the task of putting out the fire is primary and concern for their safety is secondary. Despite claims to the contrary, safety is not yet the number one priority.

Firefighters want to be safe and avoid injury, but there are times when the demands of the job obscure safe practices. To deal with these instances, firefighters need to be equipped with better situational awareness and decision making skills. And they need feedback about how they are performing these tasks. Individuals and crews seldom receive feedback. But without it, there is no way to measure performance improvements. Assessment is needed at all levels of the fire organization to establish a baseline for policy, attitudes, and behavior. As changes are implemented, measurements can determine results. Feedback at all levels is crucial for achieving positive changes.

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