Findings From the Wildland Firefighters Human Factors Workshop
Appendix D—Keynote Presentations
South Canyon Revisited:
Lessons from High Reliability Organizations1
Karl E. Weick, University of Michigan
In this paper I want to explore the idea that organizing to prevent wildland fire disasters such as the South Canyon Fire on July 6, 1994 in which 14 people lost their lives, is an ongoing struggle for alertness. My intention is to look more closely at that struggle. I want to do 4 things. First, I want to discuss 4 pieces of my earlier analysis of the Mann Gulch fire that seem relevant to South Canyon. In particular, I want to discuss briefings, leadership, tools, and wisdom.
Second, I want to discuss organizational issues at South Canyon that are less visible in Mann Gulch. These include discrepancies, levels of experience, the will to communicate, and Watch Outs involving management. Third, I want to touch on solutions. And I want to conclude by discussing some questions about South Canyon that continue to haunt me.
Similarities Between Mann Gulch and South Canyon
Briefings. The struggle for alertness at Mann Gulch was undermined by many of the same things that undermined it at South Canyon, one of which is briefings. Briefings are an attempt to give people in a crew a common framework in advance including assumptions about what they may face, how it will develop, and how the crew will function and update its understanding of what is going on.
At Mann Gulch, the crew of 14 essentially proceeded without much of a briefing. They basically knew only that they were jumping on a fire that would likely be out by 10:00 the next morning. After landing, all some of them knew was that Dodge had scouted the fire on the South slope with Harrison, had used the phrase "death trap" to describe what he found, and had ordered the second-in-command William Hellman to march the crew down the North slope toward the Missouri River. Dodge didn't say whether this tactic was to escape the death trap or to position the crew to fight the fire, or simply to get closer to the river. When the fire spotted to the North side of the gulch, Dodge turned the crew around and angled them up toward the ridge, and soon ordered them to drop their tools, and then to enter an escape fire, all without verbalizing his reasons (Dodge, 1949, p. 121). Since the crew did not know each other well, since Dodge knew only 3 of them, since several were on their first jump, and since Dodge himself was rusty on leading a crew (Maclean, 1992, p. 41), it was imperative to build some common understanding and common action into this assortment of strangers. That didn't happen.
But neither did it happen 45 years later at South Canyon. The South Canyon accident investigation team allocated almost a full page (Report of the South Canyon Fire Investigation Team, 1994, p. 26: hereafter referred to simply as Report, 1994) of their report to "Safety briefings" as a "significant contribution" to the 14 deaths. The hand-off of the fire the evening of July 5 from the BLM crew to the smokejumpers and Jumperin- charge Mackey is a good example of how not to brief people. The hand-off is by radio rather than face to face, is made after the BLM crew who know the terrain and foliage has left the scene, and the jumpers inherit a handline which is partially constructed but already lost by the time they collect their gear and are ready to extend it. Without checking whether the assumption is correct or not, the departing Incident Commander says in his statement, "I knew (ia.) that Mackey would look (sic) at fire from the air before they jumped and that he would make a decision on what to do with it after we left. I did not feel that smokejumpers needed additional guidance" (Report, 1994, p. A 5-9). Mackey got off to a bad start, and the quality of the briefings didn't improve much from then on. For example, the Prineville Hot Shots were not told how Gambel Oak burns when it is dry, nor were they told that in previous days, fires had made spectacular runs through this material in Colorado.
Why so much casualness? One possibility is that everyone seriously underestimated how much continuing effort and shared information it takes to build coordination and hold it together, especially during transitions from an initial attack to an extended initial attack, from one level of complexity to another level, and from one organization to another. The investigation team, on p. 6, states the following: "as is typical in extended attack situations, firefighting groups arrived on the fire at intervals from dispersed locations and blended into the existing organization." The key word there is "blended." Blending sounds like something that occurs automatically not something that people work at. Many would say it's especially hard to blend into an "existing organization" if that organization itself is invisible, as was the case for some people at South Canyon. Some people trying to blend did not know who the Incident Commander was, or which radio traffic had the force of authority, or what the suppression strategy was since it seemed counter-intuitive.
The questions that need to be pursued are, why does briefing continue to be treated casually and what does better briefing sound like? Back in 1949, during the investigation of Mann Gulch, Henry Thol's father understood the essentials of a briefing even if much of his emotional testimony ("I owe this to my boy", p. 201) was tough to follow. " Usually the foreman he always looked out for all, to take care of anything that happened. We always looked out for that before he put the men on the fire line. He had something to fall back on . . . let's go in there boys, the wind isn't blowing now. We'll go in there. But watch out, the wind can change any moment" (Thol, 1949, p. 200). More recently, researchers have studied effective cockpit crews in aircraft and have found that better briefing leads to better performance. This is relevant because in cockpits, as well as on fire lines, people often work with strangers. In particular, effective leaders establish and reaffirm norms of conduct for behavior in the group, and insist that people keep each other informed on what they were doing and the reasons for their actions and the situational model that gave rise to those reasons and actions. Almost no one at Mann Gulch or South Canyon heard someone say,
- Here's what I think we face:
- Here's what I think we should do;
- Here's why;
- Here's what we should keep our eye on;
- Now, talk to me.
Leadership. But Mann Gulch and South Canyon are similar not only in their casual briefings. There was uncertainty about leadership in both cases. At Mann Gulch, leadership moved uneasily among Navon, Hellman & Dodge. At South Canyon, it moved uneasily among Blanco, Mackey, Longanecker, Shephard, among others. At Mann Gulch, as at South Canyon, crew members were not closely acquainted with their foremen due to continual rotation of people among crews and assignments. (Fite, 1949, p. 28). Dodge knew only 3 people in his crew, Hellman, McVey, and Thol (Dodge, 1949, p. 125). Hellman, who was better acquainted with the men (Dodge, 1949, p. 125) was near the front of the line as they raced uphill (Sallee, 1949, p. 76) and reportedly said "to hell with that, I'm getting out of here," when Dodge ordered people to jump into his escape fire.
At Mann Gulch people were torn between 2 conflicting influences. But, the same thing happened at South Canyon. Haugh and Erickson both yelled at the retreating Hotshots to drop their tools (Report, 1994, p. 16) and run for the ridge while Thrash, who was at the head of the line of jumpers and hotshots stopped and began to deploy his fire shelter as did smokejumper Roth. Hipke and Blecha said in essence, to hell with that, I'm getting out of here and continued to run.
This similarity may be merely a coincidence. It may be more significant. It seems worth exploring, however, because it adds uncertainty to a situation that already has lots of puzzles. Uncertainty about leaders puts increased demands on crews, dispatchers, and pilots at a time when they are close to overload. Uncertainty pulls groups apart which, makes them more susceptible to panic (Weick, 1993, pp. 637-638). And uncertainty in the face of unclear leadership often cuts off the flow of information because people don't know who to send it to and responsibility keeps shifting at will. As we will see later, uncertainties about leadership were not confined to South Canyon. They extended up through the organization and this sets the tone for actions reflected throughout the organization.
Tools. A small, but powerful similarity between Mann Gulch and South Canyon is that, in both cases, when people were fleeing the blowup and were told to drop their tools so they could move faster, some resisted. Several calculations suggest that this resistance may have cost them their lives (Report, 1994, p. A3-5). They would have been able to move 15-20% faster (Putnam, 1994) without their packs and tools. Firefighters are not the only people who are reluctant to drop their tools. Naval seamen on ships are trained to wear steel-toed shoes at all times and often refuse to take them off when they are ordered to abandon a sinking ship. Fighter pilots report being reluctant to eject from the "warm womb" and "cocoon" of oxygen in a cockpit that is out of control into a far more harsh environment. It is just as hard to drop shoes or an aircraft as it is to drop a pulaski and a pack.
At Mann Gulch, Dodge told his crew to "drop all heavy tools" 200 yards after they turned upslope. According to Sallee (1949, pp. 75-76) and Rumsey (1949, p. 103) people either threw away everything or nothing. Dodge in his testimony said he "didn't know until later that they had discarded shovels and pulaskis" (1949, p. 118). Sallee reported that with the fire racing at them, smokechaser Harrison was sitting resting "and he still had his pack on" (Sallee, 1949, p. 88).
This same pattern was repeated at South Canyon. Some of the smokejumpers who deployed their shelters above the lunch spot, did drop their tools. But in doing so, they were struck by the enormous symbolic significance of what they were doing. One observed that putting down a saw was like running up a white flag (Rhoades statement); another (Petrilli), that the " Pucker factor" went up a notch (Report, 1994, p. A5-69).
What about those who didn't drop their tools? If dropping your tools signifies you're in deep trouble, keeping them may help you feel you're safe. To hold onto your tools is to stay in control, to remain a firefighter rather than a victim, to appear calm. I'm still in it. This is not just an issue of symbolism since tools are needed to scrape an area clear before deploying a fire shelter. But the reluctance to drop tools may come from other sources such as economics, habits, avoidance of failure, predictions of fire behavior, and social dynamics. Equipment is expensive and jumpers, at least, are told repeatedly and early in their training to carry out everything that is dropped to them. Habits built up during training are much more likely to involve moving with tools in hand, rather than moving and discarding tools. People have no idea what it feels like to run and discard tools or even how to do it. Rhoades in his statement mentions that as he was running to escape the South Canyon fire he kept looking for a place to put the saw down so it wouldn't get burned, a search which undoubtedly slowed his progress. In his words, "at some point, about 300 yds. up the hill....I then realized I still had my saw over my shoulder! I irrationally started looking for a place to put it down where it wouldn't get burned. I found a place I it (sic) didn't, though the others' saws did. I remember thinking I can't believe I'm putting down my saw." These words have even more impact when it is recalled that, among the fatalities, firefighter #10 (Putnam, 1994) was found with a saw handle still in his hand. To discard one's tools may signify more than giving up control, it may also be an admission of failure which, in a "can do" culture, is a devastating thing to admit.
There is a further complication with the seemingly simple act of dropping one's tools. If people drop their tools, they still face a tough choice, namely, do I now run faster or do I stop and deploy my shelter? It is tough to do both although some people at South Canyon tried. Running faster and stopping to deploy are incompatible and uncertainty about which one to do may compel people simply to keep doing more of what they are already doing, namely, running with tools. To keep running is to postpone having to make a tougher choice, especially if the person feels both exhausted and uncertain how safe the shelter really is. People may also hold onto tools because their predictions of fire behavior suggest that the fire won't reach them. This is a clear possibility at South Canyon. As the fire moved toward the hotshots and jumpers moving North along the fireline, it repeatedly was channeled toward the ridgeline along draws that ran at right angles to their movement. This fire behavior could have created the impression that the crew was at the flank rather than the head of the fire which meant there was no need to drop tools.
Finally, people may hold onto their tools as a simple result of social dynamics when people are lined up. If the first person in a line of people moving up an escape route keeps his or her tools, then the second person in line who sees this may conclude that the first person is not scared. Having concluded that there is no cause for worry or that I'm not going to be the only one who goes back without tools, the second person also retains his or her tools and is observed to do so by the third person in line who similarly infers less danger than may exist. Each person individually may be fearful, but mistakenly concludes that everyone else is calm. Thus, the situation appears to be safe except that no one actually believes that it is. The actions of the last person in line, the one whose back feels most intensely the heat of the blowup are observed by no one, which means it is tough to convey the gravity of the situation back up to the front of the line.
What hasn't changed in 45 years is the power of symbols. Packs and saws may be heavy and slow one's pace. But that may be one of their less important qualities. More significant may be their ability to reduce one's sense of danger. If throwing tools is a sign of surrender, keeping them may be a sign of a standoff or victory. It may be important for trainers to emphasize, "Look people, you're going to want to hang onto this stuff. Don't! It could cost you your life.
Wisdom. The fourth aspect of my Mann Gulch analysis that fits South Canyon centers on the idea of wisdom. To understand why the idea of wisdom fits here, you need to understand first that wisdom is a mixture of knowledge and ignorance. When one of them grows, so does the other. To know something better is also to discover that new questions about it are raised. Wisdom is an attitude that what you know is only part of what could be known, and therefore, you need to stay alert. You need to avoid excess confidence that you know everything and excess caution that you know nothing, if you want to stay flexible.
Wise organizations know what they don't know. They know two things: first, they know that they have not experienced all possible failure modes and second, they know that their technology is still capable of generating surprises (Schulman, 1993). Thus, when they act on the basis of their past experience, wise organizations act as if that experience is both credible and limited. They simultaneously believe and doubt they know what is up. Consider the case of a near miss or a close call. The fascinating thing about a near miss is that, "Every time a pilot avoids a collision, the event provides evidence both for the threat and for its irrelevance. It is not clear whether the learning should emphasize how close the organization came to disaster, thus the reality of danger in the guise of safety, or the fact that disaster was avoided, thus the reality of safety in the guise of danger" (March, Sproull, and Tamuz, 1991, p. 10). If the moment is interpreted as safety in the guise of danger, then learning should be diminished because "more thorough investigations, more accurate reporting, deeper imagination, and greater sharing of information" are all discouraged (Sagan, 1993, p. 247). The attitude of wisdom sees a near miss as evidence that the system is both safe and vulnerable, that people must remain alert, and that a safe environment is not measured by an absence of accidents (that outcome is largely dependent on luck), but is the result of active identification of hazards and their elimination (Allinson, 1993, p. 186).
At Mann Gulch, people believed they were fighting a fire that would be out by 10:00 the next morning and failed to raise questions about whether this expectation remained accurate. At South Canyon people believed they could "hook" the fire before the winds would build and they presumed that lookouts and a commander had the big picture even though the firefighters had seen no evidence of this.
The attitude of wisdom is one way to remain alert, because it leads people to remain open to what is happening and to rely cautiously on their past experience. I've always been struck by evidence suggesting that there are certain periods during a person's career, when they are most in danger of getting injured or killed. Police, for example, are in most danger of being shot during their 5th year on the force. Firefighters are in most danger of fireline accidents either in their first 2 years or after 10-15 years of experience (Pyne, 1984, p. 391). Young firefighters are vulnerable because of their inability to recognize hazardous situations. The more experienced firefighters are vulnerable because they presume they've seen it all, they have less openness to new data, thus the validity of their models decreases. The unexpected gets them.
Crews and commanders need to keep learning and updating their models. This won't happen if they presume that nothing about fires can surprise them, if near misses are treated as testimonials to safe practices, and if they are certain that they've experienced all possible ways in which a system can fail. These attitudes won't change if they reflect similar attitudes in top management. You may recall that Maclean felt "the Forest Service wanted to downplay the explosive nature of the Mann Gulch fire to protect itself against public charges that its ignorance of fire behavior was responsible for the tragedy" (Maclean, 1992, p. 125). The key word there is " ignorance." The service doesn't want to appear ignorant. Nor do it's crews. The price of creating this impression may be a loss in vigilance, learning, and wisdom.
It is tempting in a world of boldness and aggressive attacks, to conclude that there is no place for doubt. But as Thoele (1994) has suggested the best firefighters do not confuse risk with recklessness, and they are able "to say ' no' without sustaining dents in their machismo" (p. 28). That's what wisdom is about, and why it's worth striving for.
Differences Between Mann Gulch and South Canyon
Discrepancies Between Beliefs and Actions. Having suggested at least 4 ways in which dynamics of organizing in South Canyon replay themes that unfolded earlier in Mann Gulch, I now want to explore some additional issues that were less visible in Mann Gulch but that stand out in South Canyon.
The first of these is the unusually large number of inconsistencies between beliefs and actions at South Canyon. I want to dwell on these because they suggest one reason why people persisted so long doing things that violated fire orders and watch outs.
A recurring belief among people fighting wildland fires is that some of the fires they fight are on worthless land. This was a prominent issue at Mann Gulch. As Earl Cooley (1984) put it, "One of the main questions was why we risked lives and spent many thousands of dollars to save scrubby timber and cheatgrass" (p. 91). A basic discrepancy that firefighters and overhead face over and over is between their belief that the land is worthless and the reality that they are risking their lives to defend it. The action of defending is inconsistent with the belief that the area is worthless. Contradictions such as this cause tension and continue to do so until the person either changes the belief—the land is more valuable than it looks—or changes the action, and uses low priority suppression tactics. Either change reduces the inconsistency.
Let's extend this scenario to South Canyon and a key decision, the decision made at 9:30 the morning of July 6 to cut a direct fireline, downhill (Report, 1994, p. A4-6). What is noteworthy about this decision is that it involves a troublesome discrepancy. Building direct line downhill is dangerous. Longanecker said, "going downhill direct is a bad deal" (Report, 1994, A5-52). Archuleta asks, why are we punching in line? Erickson asks, "Where are the safe areas?" and hears the answer, " there really aren't any." Rhoades, Doehring, and Shelton overhear this conversation. But the decision is made to build a direct line anyway, which leaves everyone tense. They believe that the action is dangerous, yet they are doing it. What makes this really troubling is that the decision is a public, irrevocable, choice. There is good research evidence (e.g., O'Reilly and Caldwell, 1981; Salancik, 1977) that when people make choices of this kind, they are more likely to change their beliefs so that they become consistent with the action they are now committed to. In this case people should begin to believe that building direct line downhill is safe after all in order to justify what they are actually doing.
And that's what seemed to happen. Listen to how Quentin Rhoades in his own words, handled things: "I resolved not to go down that hill digging line . . . Smokejumpers arrived and started digging line. I remember thinking that I must have missed something. I hadn't been on a fire since August 18, 1992 and I felt a little green." Rhoades convinces himself that the main reason the situation seems dangerous is that it's his fault, he's rusty, he's missed something, which means the situation is not as dangerous as it looks. Other people resolve the discrepancy in other ways. They convince themselves that the leaders know what they're doing, that it won't take long to cut the line, that the predicted weather front won't be that strong, that they can "hook the fire before the front passed" (Report, 1994, p. A5-53), that the crews are really on top of this job, and that more resources are coming (Report, 1994, p. A5-47). There is a grain of truth in all of those explanations. But people also have a stake in needing them to be true, since they reduce the tension associated with doing something they believe to be dangerous. The trouble is, they now have a vested interest in not seeing warning signals. If they do notice these signals, then their whole sense of what is happening collapses. Listen again to what Rhoades says: "My ditty bag contained a copy of standard fire orders and watch situations. I considered looking at it, but didn't. I knew we were violating too many to contemplate."
When people take public, irrevocable actions for which they feel responsibility, their mind set is to justify those actions and to assemble evidence that shows the action makes sense (Ross & Staw, 1986). They are not indifferent toward evidence that raises doubt about the action. Instead they avoid, discredit, ignore, or minimize this contrary evidence and keep looking for positive reasons that justify continuing the action. People who justify their actions persist, or in the words of the investigating team, " strategy and tactics were not adjusted to compensate for observed and potential extreme fire behavior" (p. 35).
I have dwelt on this one decision at South Canyon to show how people justify their actions and in doing so, become more committed to continuing those actions. There are several other discrepancies that could be analyzed the same way, such as the belief that this was a low priority fire yet Type 1 crews were put on it; the policy that two or three trees burning is a standard smokejumper dispatch (French), yet jumpers were not dispatched immediately; the belief that this is a potentially serious fire, yet a crew walks off it the night of the 5th; the belief that retardant works only at certain stages of a fire, yet requests for it at that stage are refused; aerial reconnaissance that spots fingers of fire in west drainage on July 6, yet these are not drawn on the map (Report, 1994, pp. 26, A5-70). My point is not simply that there were discrepancies at South Canyon. Life is full of discrepancies and people manage to deal with them by sizing up pro and con evidence. My point is that, key discrepancies at South Canyon seemed to occur in a context where people got locked into public irrevocable, volitional actions, and had to justify those actions. These justifications made them more committed to those actions, which led them to persist longer in executing those actions despite growing dangers. Notice that the people who would be spared from this process of escalation would be those who were forced to cut line (there is low choice), people who saw escape routes, (the action is revocable) and people who did not express their views in public (the decision is not linked to them as individuals).
Levels of Experience. Earlier I mentioned that experience has both an upside and a downside. The upside is that it gives you more patterns that can be retrieved and matched with current puzzles to make sense of them. The downside is that more experience can sometimes lead to less openness to novel inputs and less updating of the models one uses. Failures to revise often produce ugly surprises.
I want to dig deeper into the issue of experience levels at South Canyon, partly because the accident investigation team seemed reluctant to do so. I say this because if you look at the Fire Entrapment Investigation and Review Guidelines (Report, 1994, pp. A12-3 to A12-11) which they followed religiously in structuring their report, the only category out of the 28 that they omitted was category 23, "V. Involved personnel profiles - Experience levels" (Report, 1994, p. A12-7). This omission may be due to the fact that, on paper everyone is qualified. But just because they're qualified on paper, doesn't mean that their experience is deployed well in this incident or sufficient to handle its changing character or easily adapted to it. Issues of experience levels at South Canyon are complicated, difficult to untangle, and touchy when untangled. But that's no reason to avoid them.
The overall level of relevant experience for leadership appears to be low. Several people appear to be in over their heads, which gives a whole new and somewhat chilling connotation to the personnel category, "Overhead." Experience is unevenly distributed across the several activities at South Canyon and does not always line up with authority. There are no clear mechanisms to mobilize and focus and implement the experience that is scattered around. And finally, everyone is accessing their experience under increasing amounts of stress, which means they are likely to fall back on those habits and understandings they have overlearned (Weick, 1990, pp. 576-577). Unfortunately, these may be the very habits and understandings that are least relevant to the unique conditions in South Canyon.
There are at least three reasons we need to tackle the issue of experience and how it is mobilized. First, an important finding from studies of high reliability organizations is that they have multiple structures. Aircraft carriers, for example, have a bureaucratic hierarchical structure for normal functioning during slack times, a different structure built around expertise for "high tempo" periods of extended flight operations, and a third structure explicitly designed for emergencies. High tempo structures are especially relevant for wildland firefighting where rank in the formal hierarchy does not always coincide with technical expertise. LaPorte and Consolini (1991) describe a high tempo structure on carriers this way: "Contingencies may arise that threaten potential failures and increase the risk of harm and loss of operational capacity. In the face of such surprises, there is a need for rapid adjustment that can only rarely be directed from hierarchical levels that are removed from the arena of operational problems. As would be expected, superiors have difficulty in comprehending enough about the technical or operational situation to intervene in a timely, confident way. In such times, organizational norms dictate noninterference with operators, who are expected to use considerable discretion.
Authority patterns shift to a basis of functional skill. Collegial authority (and decision) patterns overlay bureaucratic ones as the tempo of operations increases. Formal rank and status declines as a reason for obedience. Hierarchical rank defers to the technical expertise often held by those of lower formal rank. Chiefs (senior noncommissioned officers) advise commanders, gently direct lieutenants, and cow ensigns. Criticality, hazards, and sophistication of operations prompt a kind of functional discipline, a professionalization of the work teams. Feedback and (sometimes conflictual) negotiations increase in importance; feedback about " how goes it" is sought and valued" (p.32).
People in South Canyon did not seem to have the capability to form a high tempo structure where influence flowed from expertise and experience, rather than from the formal chain of command. In part, the problem was that it was never clear where the relevant expertise was located so that the structure could form around it. Furthermore, there was no clear chain of command that could defer to more experienced people nor was there a clearly understood set of signals by which such a shift in structure could be conveyed immediately and unequivocally to everyone.
A second reason the issue of experience is important is because it has the potential to create a smarter system that senses more. A key idea in system design is the notion of requisite variety: it takes a complex system to comprehend a complex environment (Miller, 1993). Analyses of South Canyon that are consistent with this principle have already begun to appear. For example, Topic 3.5 in the IMRT review states that managers should "match qualified incident commanders with the complexity of incidents" (Wildfire, Vol. 3, No. 4, Dec. 1994, p. 46). That's requisite variety. Inadequate requisite variety occurs when a less complex incident commander, or a less complex jumper crew, or a less complex dispatcher, cannot adequately comprehend a more complex event.
Requisite variety that is more adequate can be illustrated by a crew of smokejumpers who have had prior experience as hotshots. Such a crew has the capability to function either in a more independent jumper mode or a more disciplined hotshot mode, which gives them a larger variety of ways to cope with a larger variety of fire behaviors.
The notion of requisite variety also alerts us to a hidden danger in successful firefighting. There is growing evidence that success leads to system simplification (Miller, 1993), which means successful systems steadily become less sensitive to complex changes around them. This insensitivity culminates in a sudden string of failures and the horrifying realization that one has become obsolete and faces a nasty, prolonged period of playing catch-up.
Again, the lesson from high reliability organizations such as the Diablo Canyon nuclear power plant is the need to cultivate diverse experiences, variety, multiple points of view, and conceptual slack (Schulman, 1993) so that people have a better sense of the complexity they face. And, there also need to be well-learned, trusted, procedures to handle the inevitable conflicts that arise when people make different interpretations, such as when a Fire Management Officer and a Hotshot superintendent differ on how the fire should be fought.
The third and final nuance of experience that I want to raise is the question of what happens when you are at the limits of your experience where demands exceed capabilities? And what can be done about it?
For the sake of illustration, let's look at jumper Mackey who was jumper-incharge at South Canyon and who had just recently been given a permanent appointment. What's interesting and troubling about Mackey's position is that the system makes it hard for him to do a good job on this fire. If we put ourselves in Mackey's shoes we discover that he is in a bad spot almost from the start.
He starts with a sloppy hand-off the evening of July 5 and an unfinished project which he is unable to continue. He's dropped on unfamiliar terrain, at twilight, with rolling debris and steep slopes. The crew is unable to get much sleep. The resources (two Type 1 crews) that Mackey requests the night of the 5th arrive in small numbers at unpredictable intervals the next day (8 jumpers at 10:00 a.m., 10 hotshots at 12:30 p.m., another 10 hotshots at 3:00 p.m.) and Mackey is not even sure they'll come at all since he's been told his fire is low priority. When there is disagreement about building line direct and downhill, the incident commander does not resolve it and the hotshot superintendent does not seem to question the strategy when he arrives around noon (Report, 1994 pp. A4-6, A4-7).
At some level Mackey knows the downhill strategy is risky because, in response to a flare-up at 10:35 AM, he begins to pull the crew out (Report, 1994 p. A5-70) only to have that decision questioned by Longanecker who suggests doing bucket drops. The drops are made and the crew resumes cutting line. Not long after this Rhoades observed that "Don looked terrible." Still later, when the saw Rhoades is using breaks down, Mackey offered to sharpen it and help him cut line. This looks like a clear instance of a person falling back on overlearned behavior when that person is under pressure. Mackey discards the less familiar activity of keeping your head up and supervising for the more familiar activity of keeping your head down and cutting line.
I mention this example to make the point that when demands exceed capabilities, which is the basic condition under which people experience stress (McGrath, 1976), this is seldom simply the fault of an individual. The buck doesn't stop with that person. Instead, the buck stops everywhere (Allinson, 1993). The people around Mackey made his assignment harder and reduced his capabilities to handle it. The resulting pressure made it harder for Mackey to gain access to the experience he already had, which increased pressure when his decisions were questioned, which gave him even less access to his experience until he was caught in a vicious circle where he did what he had always done on fires, namely cut line rather than supervise. The Hotshots had no idea something like this might be developing, and when they saw Mackey, he seemed to be moving around and checking, which is what overhead is supposed to do.
The system let Mackey down. It did little to remove or redistribute pressures, it did little to simplify his assignment, and it did little to monitor the fact that he and others had less and less energy to cope with growing complexities. The crew was losing variety and alertness, and no one spotted this or slowed the loss, or altered the work so that whatever alertness remained was sufficient.
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