Appendix B: Findings From the Wildland Firefighters Human Factors Workshop, 9551-2855-MTDC

Findings From the Wildland Firefighters Human Factors Workshop

Appendix B—Agenda

Keynote Presentations
(open to the public)

0800–0900
Behavioral Bases of Accidents and Incidents: Identifying the Common Element in Accidents and Incidents
Curt Braun, Ph.D., University of Idaho

Human behavior plays the largest role in firefighter safety. Faced with the known and essentially constant risks of a wildland fire, human behavior is the only factor that can greatly increase or decrease the risk of injury. Despite its large role in safety, however, behavior is frequently overlooked during accident investigations. Endeavoring to discover the cause of a workplace injury or fatality, investigators often focus on the special environmental circumstances and not on the behaviors that preceded that accident. This overemphasis on circumstances fails to consider the fact that the vast majority of accidents result not from the environment but from known risky behavior that is part of common work practices.

To address safety challenges, specific consideration must be given to the element common to all accidents: human behavior. A behaviorally based safety program can reduce the risks associated with wildland fire suppression by: (1) identifying antecedent behaviors that lead to accidents; (2) determining the frequency of these behaviors; (3) evaluating the training programs and management systems that either directly or indirectly support the behaviors; and (4) developing a training and management remediation program aimed at changing behavior.

0900–1000
Recognition Primed Decision Strategies
Gary Klein, Ph.D., Klein Associates

Studies of firefighters show that they rely primarily on Recognition-Primed Decision (RPD) strategies as opposed to sifting through alternatives and comparing how they rate on different evaluation dimensions. The RPD model explains how people can make decisions under conditions of time pressure and ambiguity and shifting conditions. Specifically, the model explains how experienced decisionmakers can generate a reasonable course of action without having to contrast alternatives, and how they can evaluate a course of action without comparing it to alternatives.

We can also use the RPD model to understand some of the errors that can arise in naturalistic settings. These primarily stem from inadequate experience bases. In turn, these error types suggest some strategies for decision-centered training.

1000–1100
The "Cultural Inertia" Impacts of Team Decisionmaking
David Hart, TIG, Inc.

Cultural attitudes permeate the decisionmaking of teams working within the organization. "Anytime, Anywhere," " Can Do," and "Make It Happen" are examples of adopted cultural attitudes that have both assisted and (in some cases) inhibited crew effectiveness. This discussion investigates the impacts of cultural-based attitudes as barriers to individual and crew decisionmaking processes. It includes discussion of lessons learned from other high-risk/high-threat environments in establishing a nonattribution/ non-retribution environment, and overturning cultural attitude barriers within the individual and the organization as a whole.

1100–1200
South Canyon Revisited: Lessons from High Reliability Organizations
Karl Weick, Ph.D., University of Michigan

There is an emerging body of work that has begun to describe how organizations that face the possibility of catastrophic error every day, cope with this prospect. These organizations, referred to as high reliability organizations, include nuclear power plants, air traffic control systems, aircraft carriers, flight crews, and chemical plants. Several issues that are discussed in studies of these organizations are similar to issues that have surfaced in discussions of the South Canyon Fire incident on July 6, 1994. The purpose of this presentation will be to discuss some of these similarities with special attention being focused on issues of communication, group structure, stress, mindsets, leadership, and sense making.

1200–1300: Lunch
Closed Workshop Session Begins (limited to invited participants)

1300–1700: Focus will be on the dynamics of individual decisionmaking and individual firefighter experience

1830–: No-host bar and dinner (if there is sufficient interest)

1200–1300: Lunch

1300–1700: Focus will be on interactions between crews and organizational structure

0545: Assemble at Village Red Lion Inn and board bus

0600: Depart Missoula

0600–0800: Workshop discussions enroute

0830–1800: Mann Gulch guided tour

On August 5, 1949, a wildfire overran 16 firefighters at Mann Gulch. There were only three survivors. Significant controversy has surrounded this fire, including firefighter decisions and actions as well as the ensuing entrapment investigation. On July 6, 1994, a wildfire overran 49 firefighters at South Canyon. There were 35 survivors and 14 fatalities. Many investigators believe the two events are connected and ask how much have we learned in the intervening 45 years. A trip to Mann Gulch has been planned to explore that connection and foster further workshop dialogue in a "real life" setting.

Mann Gulch is about 150 miles east of Missoula and 25 miles north of Helena, Montana. A bus will leave the Village Red Lion Inn parking lot promptly at 0600. It is about a 2-½ hour drive to the Gates of the Mountain Marina and about a 30-minute boat ride down the Missouri River to Mann Gulch. We are paying for the bus, but each participant will need to pay about $10 for the boat ride (round-trip). We will return to the marina around 1730-1800 and will be back in Missoula by about 2000. Each participant should bring a sack lunch and a canteen of water as well as snacks for the return trip. In addition, bring clothing appropriate for the weather, as well as other items desired such as cameras, daypacks, and so forth.

We plan to have two guides knowledgeable about Mann Gulch available to retrace the events. An EMT with a first aid kit and radio will also accompany us.

The walk up Mann Gulch is about 1-½ miles over grassy, rocky ground. Sturdy work or hiking boots (well broken in) are strongly recommended. The slope is steep, but people of varied fitness levels have tackled it successfully walking at their own pace. Snakes and footing are the only other hazards, though snakes are rare. The trip will be canceled if rain or strong winds are forecast. More information will be provided at the workshop.

1800–2000: Return trip to Missoula

1200–1300: Lunch

1300–1700: Workshop recommendations

Appendix B—Agenda

Suggested Reading: