Findings From the Wildland Firefighters Human Factors Workshop
Appendix D—Keynote Presentations
South Canyon Revisited:
Lessons from High Reliability Organizations1
Communication. In the preceding discussion of levels of experience, I steadily enlarged the size of the relevant organizational unit from jumpers and hotshots and South Canyon overhead, to the system in general including dispatcher, interagency coordinators, and top management. I did so in the hope that we would not fall into the trap of glibly saying that South Canyon is another instance of operator error, but would instead incorporate a larger, earlier, higher set of design decisions as significant contributors to the incident.
You may recall that the team investigating South Canyon felt that " Management support and dispatch coordination" were not "significant contributors" to the disaster, but merely " influenced" it (Report, 1994, p. 33). I mention this partly because not everyone agrees with this assessment (e.g., OHSA, IMRT), and partly because this is the same kind of questionable assessment that was made by the team investigating the Challenger disaster. In the Challenger report, the Main Cause of the disaster was listed as " failure in the joint between the 2 lower segments of the right solid rocket motor" (Allinson, 1993, p. 111) and the Contributing Cause was listed as flaws in the decision making process. The implication of such an analysis is that people should devote the brunt of their energy to correcting the main cause.
Allinson (1993, p. 111) among others has argued that the Challenger investigating team had their priorities reversed. The failure was set in motion by actions and choices that said it was safe to launch and by the decision to launch itself. The defect in the O-ring can't harm anyone as long as that defect stays on the ground. The fact that a defective design even "existed at all was the result of previous decisions to select this design. That it was allowed to continue to exist was the result of previous decisions not to alter it, despite repeated warnings. That it was allowed to be in use in unsuitable weather conditions was also the result of decisions made to allow it to operate despite the danger that the weather conditions represented. [Allinson concludes by saying] It seems more appropriate, then to describe the technical defect of the Challenger with the term "proximate cause" and management's decision to launch the Challenger without an adequate regard for safety, the 'primary cause' " (p. 113).
Since the South Canyon report focuses on the crews cutting line, it is difficult to spot earlier administrative decisions that are potentially significant. But there is certainly no shortage of possibilities. Crews at South Canyon are told to be aggressive but are given little support to do so and later are faulted for being too aggressive. Prineville Hotshots are requested and then treated poorly when they arrive at the Glenwood Springs office at 8:00 a.m. on the 6th (Report, 1994, p. A5-80) where they are forced to look around to find tools and then go to the 7-11 to get food. Their understandable agitation at being handled this way probably does not disappear the moment they get to South Canyon. Instead, much like the married pilot who takes command of an airplane shortly after an intense domestic quarrel, the crew starts their work at a level of stress which is already quite high. It doesn't take much additional stress before the quality of their judgment and thinking may begin to suffer. Radio discipline is practically non-existent (Report, 1994, p. A5-37). Dispatch keeps reminding people that South Canyon is a low priority fire, that there is nothing out of the ordinary (LaDou statement), and they keep saying "Roger" to all requests for resources without any feedback as to how and when the request will be handled, if at all. Requests for retardant are denied, weather briefings are unevenly distributed, and no one takes responsibility for better distribution. The IC is invisible (Report, 1994, p. A5-67) and there is no guidance for helicopter use which means that people compete continuously (Byers statement) for its services (Report, 1994, p. A5-22). These poorly integrated managerial decisions are spread over the period from July 2nd through the 6th and may reflect even earlier decisions about safety and how people are to be treated.
The questionable decisions continue after the blowup, suggesting that the incident within the incident is mishandled. Aircraft are kept circling above the blowup for 45 minutes in 50 knot winds (Ferneau statement). The governor is allowed to tie up a key phone connection for 15 minutes which delays rescue efforts for the people deployed in shelters. Helicopter pilot Good, who seems to have a stunning amount of endurance and resilience, is still being ordered around at 9:00 at night, this time to fly body bags in. He speaks for a larger group when he refuses, saying, " I've had enough" (Report, 1994, p. A5-50).
These are all symptoms of problems far removed from the crew boss on the ground, and our job is to diagnose symptoms of what. Many would say these are symptoms of problems in communication. This is what the Hotshots said: "The crew wants to know where the communications broke down with the red flag warning" (Report, 1994, p. A5-81). The answer to their question about a breakdown is that the communications broke down everywhere, which is an inevitable diagnosis when you argue that the buck stops everywhere.
Here's what good communication looks like. The example comes from Winston Churchill. When he discovered to his horror that Singapore was vulnerable to a Japanese land invasion during WWII, Churchill said, "I ought to have known. My advisers ought to have known and I ought to have been told and I ought to have asked" (Allinson, 1993, p. 11). Notice how much complexity Churchill has described. There is no one cause for this disaster. Churchill could have known. Others should have known. Those who should have known, should have informed Churchill without his asking. If others did not know, they should have found out and informed Churchill on their own without waiting for him to ask. If they didn't know, Churchill, by inquiring of them, might have prodded them to find out. If they had known but failed to speak up, Churchill, by inquiring, may have been given the necessary information. Any of these eventualities might have changed the course of events (adapted from Allinson 1993, pp. 11-12).
It is everyone's responsibility to challenge and to respond to the challenges in a trustworthy manner, and to listen carefully and respectfully to the response. When people fail to engage in respectful interactions (Weick, 1993, pp. 642-644), things can get dangerous. Let me suggest why that happens.
One possibility in wildland firefighting is that a norm has developed which says essentially, no news is good news. Partly because people on crews are independent, adventuresome, take charge people; partly because radio traffic is so hard to control; partly because there are no detailed and systematic communication protocols for dispatchers and crew leaders to exchange information about changes in fire status; and partly because people presume the basic task itself is straightforward, a failure to report is treated as a positive message that things are OK. Notice, that if things are not OK and people are preoccupied and unable to send a message, this too will result in a failure to report.
Thus, no reporting can mean either things are OK or things are not OK. The Zebrugge Ferry disaster on March 6, 1987 involved this very misunderstanding. The person responsible for closing the bow doors of the ferry did not report any deficiency to the Captain, not because there was none, but because he had fallen asleep before closing the doors. The Captain steamed into the channel unaware that the doors were open and water was flowing into the vessel. Five minutes after leaving the coast of Zebrugge, the ferry Herold of Free Enterprise capsized, sank, and 193 lives were lost. The buck stops everywhere on this incident. Virtually the same scenario happened 5 years earlier on October 29, 1983 aboard the ferry Pride, but was caught before the ship capsized. At that time, the Master urgently communicated with management requesting that there be some indication on the bridge whether the watertight doors were closed or not (Allinson, 1993, p. 203). Management did not listen. Their responses to this request are preserved in the accident investigation and included remarks such as, "Nice, but don't we already pay someone?"; "Assume the guy who shuts the doors tells the bridge if there is a problem"; "My goodness." People at the top didn't feel it was part of their job to inquire, or to listen attentively, or to pass along information. So there is no reason for the Masters' of the vessels to act differently if this is the preferred communication style at the Peninsula and Oriental Steam Navigation Company (Allinson, 1993, p. 195).
People associated with South Canyon didn't know a lot of things they should have known. This raises at least 3 questions: why weren't they told, why didn't they ask, and why didn't they tell what they knew? They may not have been told because others thought the information would have no effect, was not desired, or would not be passed on. They may not have asked because they thought they had all the answers or wouldn't get them anyway. And they may not have passed on information because they assumed it would not receive a hearing. If any of these possibilities are true, and if people also believe that no news is good news, then wildland firefighting is a thousand administrative accidents waiting to happen and is even more dangerous than people realize. Fire is not the problem. The problems are alertness, trust, trustworthiness, respect, candor, and "the will to communicate" (Allinson, 1993, p. 41), a list that fits Mann Gulch as much as it fits South Canyon. The difference is that in South Canyon, the list applies to a more dispersed set of people with a more diverse set of interdependent tasks.
Safety attitudes are inherent in good management practice rather than something that are tacked on. Free flow of information is good management practice, gets things done, and saves lives. If people fail to pass along information, fail to listen attentively, and fail to elicit information actively, that is bad management and unsafe management. I suspect Stephen Pyne (1984, p. 394) has it about right when he said that "All too often 'safety' is a cosmetic, a mandated and barely tolerated veneer of declarations, memorandums, task force reports, safety officers, and exhortations that has little relevance to the conduct of practical affairs. Something is taught as a 'safe' procedure rather than the only procedure. Safety is something added to a program, not something integral to it . . . Most safety programs fail at the bottom because they are not truly practiced at the top."
Watch Outs for Administrators. In the context of a closer look at administrators, it makes sense to look at the 10 fire orders and 18 Watch Outs that are potential guidelines for firefighters, guidelines that remained on a card inside Rhoades' ditty bag, untouched and unread. I want to make two points about these two lists. First, I think firefighters should begin to compile a list of Watch Outs for administrators. In the same way that the current 18 Watch Outs alert crews to increased hazards at the site of the fire itself, administrator Watch Outs would alert crews to conditions back at headquarters that are just as hazardous as the fire itself. Recall that Longanecker (Report, 1994, p. A5-54) proposed just such a watch out in his statement after South Canyon: Watch out "when you don't receive the resources that you need or you are debating with the dispatcher about the resources you need." A handful of other Watch Outs might include, Watch out,
- When the governor is in town (Report, 1994, p. AF-64);
- When interagency ties are strained (Report, 1994, p. A5-63);
- When dispatchers keep track of things in their head rather than on paper;
- When the norms for radio discipline are loose (Report, 1994, p. A5-37);
- When people are reluctant to ask for help;
- When administrators are getting on-the-job training;
- When administrators say "keep it simple;"
- When the overhead is tough to find (Caballero statement); and
- When you don't know which office to report to, you think about it, and having thought about it you then go to the wrong one (Taft statement).
The second point I want to make is that a good place to start in developing a list of administrative Watch Outs is with existing efforts to boil the ten fire orders down to the acronym LCES (Gleason, 1991). If lookouts, communication, escape routes, and safe areas, are good enough for firefighters, they are good enough for administrators. The principles are essentially the same in either case. For example, the administrative counterpart of lookouts is a person with the big picture. In nuclear power plant control rooms, there is a person called the shift foreman (Weick, 1987, p. 116) whose sole responsibility is to maintain the big picture. The most effective aircraft cockpit crews are those in which, during an emergency, the aircraft is flown by the first officer (copilot) not the captain and the captain plans how to deal with the emergency and tracks progress.
Although, I have already discussed communication, a good way to illustrate it is by a surprising finding in studies of captains who lead the best aircraft crews. Investigators found that these captains readily acknowledge that their decision making ability is not as good in times of emergency as it is at other times (Helmreich, Foushee, Benson, & Russini, 1986). Captains who are the worst leaders, say that their decision making ability is just as good in time of emergency as it is at other times. Poor leaders don't listen because they don't think they need to. Good leaders don't fall into that trap. Recall an earlier point I made that a potential trap when people gain experience is that they lose openness to new information. Here we see clear evidence that good pilots—and by extension, good leaders in general— don't let that happen.
Escape routes for administrators consist of things like options, revocable actions, pulling the plug, seeing the temptation to escalate a commitment to salvage a losing cause and then avoiding it. The scary thing about administrative escape routes, is that sometimes they are used to deny individual responsibility and to pass the buck. That's the mind set that we want to undercut with a culture where the buck stops everywhere. Managers responsible for treating people with respect need to have the welfare of those people in mind and not just their own reputation, when they vow never to get into anything without having a way out for everyone. Safe flight operations on aircraft carriers are made possible because that's precisely what managers believe and put into practice (Weick & Roberts, 1993).
Safe areas for administrators are created by such things as clear norms about the relationship between failure and learning, secret ballots, anonymous reporting of near misses, access to brainstorming where evaluation of ideas is intentionally suspended, the equivalent of a penalty box where people who commit glaring errors are put for a finite period of time after which they rejoin the action, and availability of 3rd parties to mediate conflicts that are difficult to resolve. It is the very availability of these safe areas that allows administrators to act in a candid manner that can then be mirrored on the fireline.
If a firecrew sees that management is violating its own version of LCES, they should be just as wary and alert as if they saw themselves violating LCES at the fire itself. The dangers, in either case, are real, immediate, and serious.
Moving Toward Solutions
My analysis so far has been largely speculative and has consisted of extrapolations from what is known about high reliability organizations to seemingly analogous circumstances in South Canyon. Given the tentative quality of this diagnosis, it is premature to talk about remedies. Nevertheless, remedies have already been implied in what I've said and I want to illustrate briefly some directions in which those implications point.
- If leadership is an issue, then it seems important to look more
closely at the possible pathways by which one can become a smokejumper
foreman, whether the route is through expertise with parachutes, or
with leadership, or with fires. Depending on which route is favored,
people in the field could have very different habits they fall back
on when put under pressure.
- If people feel there are too many rules binding on firefighters
(10 fire orders + 18 Watch Out situations + 4 LCES + 4 common denominators
+ 3 sources of judgment error [ignorance, casualness, distraction]
+ 9 guidelines for indirect/ downhill line construction = 48, in Gleason,
1994, pp. 24-25), and if firefighters say they need to violate orders
to keep fires from growing (Rhoades, 1994, p. 22), then clearly some
priority setting is in order. It is here where I think it makes sense
to talk about simultaneous centralization and decentralization. What
you want to do is centralize everyone in terms of 3 or 4 key values
which are treated as non-discretionary and imperative (LCES?), and
decentralize the others issues so that they serve as guidelines and
a platform for improvisation to meet unanticipated local conditions.
I have no idea what the final partitioning of Gleason's 48 guides
would look like. I do know that discussions to hammer out such a partitioning
would strengthen the will to communicate.
- I would pay close attention to what people overlearn during their
training, since this is what they are most likely to do when put under
pressure. For example, the 23 people (Report, 1994, p.14), who fled
from the ridgeline did not take the shorter, safer, more direct route
used by Haugh, Hipke, and Erickson, but instead ran out the same way
they had hiked in, which exposed them to more danger for a longer period.
If firefighters haven't practiced and overlearned shelter deployment,
or dropping their tools, or using a checklist, or watching out for
the safety of a buddy, or running from fire as fast as possible (Maclean,
1992, p. 272) over and over, then it's a safe bet they won't
do those things either when they are under intense pressure.
- I think Dave Thomas (1994, pp. 45- 48) is right in his insistence
that fire stories and case studies are a crucial means to extend people's
repertoire of experience, even if that experience is second-hand. There
certainly are enough "old fire dogs" around to make it
possible for live cases to be made a regular part of training. Our
research on socialization of newcomers on aircraft carriers suggests
that old hands who tell war stories are an invaluable source of training.
Remember, we're talking about organizations in which it is hard
to learn by trial and error. The next error may be the last trial.
If trial and error learning is limited, then case studies become very
important.
- I think there is a key training lesson in the recent experience with airline training in cockpit crew management. This training didn't have much effect or credibility until the people being trained were put in flight simulators where they solved in-flight problems and were video-taped doing so (Helmreich and Foushee, 1993, p. 28). Pilots saw themselves actually committing the errors that up to then, had only been described in dry classroom lectures. And what may have been most crucial in this Line Oriented Flight Training is that each videotape was erased immediately after the performance had been critiqued. Videotapes of crew interaction during fires, of dispatchers allocating scarce resources, or of administrators briefing local property owners, all could prove to be a valuable window on just how well the struggle for alertness is being waged.
I know these are all small solutions to potentially big problems. But they are a start, they can be done in parallel, they can be done simultaneously in different places, and they may stimulate a better set of starting points.
Lingering Questions
Even though I have some hunches about what might have been going on in South Canyon, there are some questions that continue to baffle me. For example, how is it possible that so many fire orders and Watch Outs were being violated (20/28 were violated according to the South Canyon investigation team, p. 3), enough violations that Rhoades was scared to count them, yet Ryerson is quoted in the Wall Street Journal (8-22-94) as saying " it happened fast enough that none of us knew we were in danger . . . It happened in a matter of seconds" (Page A1, column 1) and Blanco called dispatch shortly before the blowup "and told them that things looked good" (Report, 1994, p. A5-11)? I realize that Ryerson probably means the blowup itself happened fast, yet conditions had been steadily worsening and the blowup was not the first moment people sensed danger. People either weren't keeping score of the number of violations, or didn't want to know the score, or because they arrived at different times with different information had a different sense of the number of violations.
A different set of questions concerns the role that groups play. Why didn't the Prineville Hotshots speed up, look back, drop their tools? Perhaps they didn't think they were in great danger. The fire could have burned straight uphill toward the lunchspot. But what we may also be seeing here is the flip side of what I think happened at Mann Gulch. At Mann Gulch the group disintegrated, which led to a loss of meaning and then to something approximating panic. At South Canyon the group remained together (Report, 1994, p. A4-10) and things stayed meaningful, but people held onto the wrong meaning. Imagine what a typical hotshot might be thinking. Erickson and Haugh are strangers and jumpers to boot; they are saying "run," but this has been a sloppy operation from the start. Furthermore, we didn't hear anything about a weather front nor did we hear the argument about cutting direct line downhill, so presumably we're safe and they're probably exaggerating.
It may be that group ties were too tight among the hotshots, the level of concern was too low, and the meaning persisted, like it did at Mann Gulch, that this is just one more 10:00 fire.
Perhaps there is such a thing as a group being too disciplined and too cohesive. High cohesion wards off panic, but it also encourages groupthink and wards off more disturbing and more varied meanings of what may be happening. Variety may have been crucial to surviving this incident. The 12 people climbing up the fireline toward the ridge all did the same thing and perished. The other 37 people on the mountain did different things, most of which worked. Three ran to the top of the fireline; 8 ran above the lunch spot and deployed shelters; 1 stayed at the lunchspot; 23 headed for Helitack 2 but then stopped and went down various portions of the east drainage; and all of these people lived. Two people tried to make it to Helitack 2, but failed. To put it in the most extreme form, the hotshots didn't panic and that may have been their problem. If they had come closer to doing so they might have lived. I know how bizarre that sounds. But it's important to realize that we are dealing with strong, competing, human tendencies toward independence and conformity. That lies behind respectful interaction. People need sufficient social support to stay calm and sufficient independence to be innovative. People who fight wildland fires aren't freed from this dilemma simply because they are bold. As long as crews and danger and different experiences mix together, we can expect puzzling outcomes.
Notice that we can take a totally different approach in analyzing the Hotshots' behavior. Earlier, I argued that because they were poorly treated in Glenwood Springs, they may have been under some stress when they got to South Canyon. If, in addition, they had doubts about the safety of what they were doing, then the level of stress might have been quite high when they were ordered to retreat to the ridge. If, during hotshot training, people overlearn paramilitary discipline, regimentation, and obedience, then we would expect this pattern of discipline to be especially visible under high stress. The general idea is that when stress increases, people fall back on overlearned habits. Thus, the brisk, well-spaced, steady march up the fireline toward the ridge with tools in hand, may represent the behavior of a group under enormous pressure rather than that of a group that is relatively calm and thinks this is just another fire, albeit one that has been has been managed a bit more poorly than usual.
A further puzzle at South Canyon concerns the possibility that this fire fell in a kind of "no man's land" at a crucial period. Jumpers who dropped on the fire the night of August 5th found a fire that seemed larger than an initial attack fire for which they are experts. When the shots began trickling in around noon on August 6th, they found a fire that seemed smaller than fires for which they are experts. The result is a fuzzy situation where the fire is too big for some, too small for others, and too foreign to the experience of the people in charge. The problem may not be that a transition was mishandled and resulted in fatalities. Rather, the problem at South Canyon may have been that the complexity of the fire fell outside the scope of everyone who tried to control it. If that's plausible then it suggests the need for rethinking the adequacy of existing fire categories and their matchup with training and expertise. Problems may occur not only when fires move from one category to another, but also when they defy categorization in the first place.
As a final lingering question, I wonder if 48 guidelines might be too few guidelines to be of much help to firefighters? There seems to be lots of overlap and similarity among the guidelines, so much so in fact that if we study them closely, we might discover that they have too little variety to match the large amount of variety in wildland fires. If that were possible, then it would explain why firefighters feel they have to violate orders. They do so to regain the variety of attack they feel is necessary to combat the variety in the fire they face. The possibility that 48 guidelines actually reduce requisite variety is also consistent with the idea that these guidelines may serve the function of deflecting blame from administrators onto crews, and are only incidentally relevant to safe practice. With this many guidelines in place, it's fairly easy after the fact for administrators to spot at least one violation that occurred and to spotlight it as THE cause of the accident.
My point here is not to be cynical. Instead, I want to raise the possibility that the system may know less about firefighting than it thinks it does. The multiple guidelines give the impression that much is known, but the guidelines may be redundant, they may say the same thing in several different ways. The result may be that when people take these guidelines seriously they reduce their ability to sense subtle variations in fire behavior and therefore undertake more dangerous actions. The guidelines may shield management, but they also may create blindspots for firefighters. I think that possibility needs to be explored carefully.
If it turns out that the 48 guidelines say just a handful of different things and anticipate a relatively limited set of variations in fire behavior, then efforts should be made to develop a more comprehensive, more varied set of guides. If it turns out that all 48 are different, varied, and necessary, then it would seem important either to prioritize them as mentioned earlier, or divide up responsibility for them among the crew. If there are 48 guidelines and 10 crew, then each crew member would be assigned 5 guidelines to monitor, champion, and communicate.
Conclusion
Something that both Mann Gulch and South Canyon share in common is a series of events in which something very small escalated into something monstrous. A good example of two events that can be caught in an escalating spiral that starts small and ends monstrous are the events of "fear" and "understanding." As fear increases, understanding decreases, which causes fear to increase even more, which leads to even less understanding, and this escalation increases until something explodes. That could be what happens as people discuss how to prevent more South Canyons. But if the discussion leads to more understanding, then we create a world where more fear leads to more discussion which leads to more understanding which leads to less fear. My remarks should be understood as an invitation to discussions that improve our understanding and lessen our fears.
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1 Paper presented at Decision Workshop on Improving Wildland Firefighter Performance Under Stressful, Risky Conditions: Toward Better Decisions on the Fireline and More Resilient Organizations, Missoula, Montana, June 12-16, 1995. I acknowledge with appreciation the generous assistance of Ted Putnam in the development of these arguments, as well as the inputs from other participants in the decision workshop. I also thank David Thomas and Paul Gleason for their continuing encouragement. Please direct any correspondence concerning this manuscript to Dr. Karl E. Weick, School of Business Administration, University of Michigan, Ann Arbor, MI 48109-1234. Telephone: (313) 763-1339.
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