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

Findings From the Wildland Firefighters Human Factors Workshop

Workshop Findings

[photo] Dave Thomas showing Ted Putnam and Dave Turner Wag Dodge's escape fire.
Dave Thomas points toward Wag Dodge's escape fire while
Ted Putnam and Dave Turner consider his analysis.

The first three days focused primarily on determining where the fire community is organizationally, where it should be going, and how the needs of both the firefighters and the fire organization could be brought into closer alignment, with safety the first priority. Workshop participant inputs were organized into three areas:

reorganization strategies for fire agencies based on HRO's;
fire management Incident Management Team (IMT) and fire crew reorganization using CRM as a model; and
better assessment and feedback. The fourth day focused on future organizational studies, changes, and training that would move safety to the forefront and improve firefighter attitudes and effectiveness.

Fire Organization and Culture

The wildland fire agencies should compare themselves with HRO's and use research results to improve the agencies.
Fire crews should be organized using relevant CRM concepts for improved safety and effectiveness.
There is a need to clarify management and public expectations of firefighters. Management and the public need to be more realistic in their expectations of the fire community. We should not feel pressured to do more while resources continue to dwindle. We cannot always do a good job with what we have now, and the situation is getting worse. There are too many conflicting messages about safety first versus getting the job done.
- Maximizing forest growth means more severe fires in the future.
- Often politicians and the public exert pressure to go all out to save homes in the interface.
- Unqualified personnel are making firefighting unsafe. This includes inexperienced EEO, downsizing laterals, and others who have not worked their way up in the fire organization with a combination of training and experience.
- Lack of financial and position incentives to keep experienced firefighters in the organization.
- We taught the public we should and can control all fires. Now they expect us to fight all fires with people, planes, helicopters, and retardant. This has led to higher cost fires and more risk taking in the sky and on the ground. There is a real need to re-educate the public about all the issues of fire management. We need to return to a more natural view that all fires are not stoppable in the same sense that we cannot stop hurricanes, earthquakes, floods, and other natural events.
- Management needs to redefine " success" and "failure" in firefighting, together with priorities and consequences. Evaluate all messages against agency goals especially the goal of safety first. Eliminate miscues.
It is easier to modify behavior than attitudes. Changing attitudes occurs after a 3- to 5-year effort. Attitudes need to be exemplified in behaviors.
Agencies are not well organized to handle extended initial attack and transition fires, where most fatalities occur.
The current fire culture does not foster respectful interaction. If a fire is going to blow up, is it culturally acceptable for anyone to voice an opinion? Do all firefighters have the courage to raise this point? All firefighters should be allowed to verbalize their fears. Firefighters should be given situational assessments in a respectful context. When the situation is unsafe, they should also be allowed to pull back without loss of respect or threats. There is a need for organizational clarity on factors involved in not engaging or disengaging, and when these factors align to result in action to pull back. Some crews and crew supervisors have a good, experience based comfort level for when to pull out, whereas others do not.
Firefighters need to be responsible for their own destinies and help work through the "more with less" period. It will be worth it in the long run.
We need to identify constants between firefighters' attitudes and management, and identify firefighter rituals, norms, values, etc.
What is controlling fires about? What are we trying to do? Who is making sense out of all this—fire management? Firefighters? Are we on the same mission? Whose vision?
Are rational models of fire organizations synchronized with the informal work culture?
Worsening organizational strains include mixing personnel, declining experience levels, uncertainty of experience, under-funded training, downsizing, then placing laterals and EEO personnel with little or no experience in high responsibility fire positions.
There is a critical organizational need to rebuild a sense of community from the top down and the bottom up, because it seems to be disintegrating now. If it takes up to six weeks for crew cohesion and trust to develop, are people and crews really interchangeable as managers presume? Are there better ways to accelerate cohesion and trust? Continually emphasize the fact that the humanity of the fire community is far more precious than any other resource. Remove barriers and inconsistencies between cultural expectations and actual practices. Promote better cohesion.
Cultural differences between groups of firefighters:
- The public and firefighters promote group images that pressure "elite" groups to "aim to please" and "live up to expectations."
- The group culture affects risk taking and decision making.
- More respectful interactions are needed to bring expectations into line with capabilities, for a better sense of community.
- Management and IMT's need to take group differences into account.
- Elite crews need to feel that they are allowed to back down from risky, unsafe actions without any loss of respect.
- Crews of different racial mixes have unique cultural concerns.
Too many red-carded personnel do not have the expertise indicated by their cards and positions on fires. As a result a mistrust of all individuals is growing, and this in turn is a mistrust of the organization. There is an "us" versus "them" attitude between firefighters on crews versus IMT's or FMO's and dispatchers. Most of the training opportunities, hence higher red card ratings, go to PFT's as opposed to seasonals who have considerably more fire experience. Filling fire vacancies with engineers, foresters, and EEO candidates rather than seasonals further undermines the experience base, and it is getting worse. Creating unsafe managers through hiring practices flies in the face of upper level management pronouncements about safety first. These "new" fire managers who do not see the big fire picture often are overzealous micromanagers. The agency needs to take a hard look at qualifications of FMO's and dispatchers. They need CRM type training to better size up situations, make good decisions, and communicate the outcomes in an open, two-way atmosphere. There are too many incompetent people on the fireline. The red card system is failing, which puts more firefighters at risk. New evaluation processes such as "hot-seat" simulations, panel reviews, etc., are needed for key decision making fire positions, to eliminate the possibility of one person being able to sign off another in a " buddy system" because of perceived pressure or because the organization needs them. The rating system must be consistent throughout the nation and between agencies.
Management needs to stop talking and promote actions that foster real changes in the organization. Policymakers could use decision making and situational awareness training.
Working safely is a natural outgrowth of clear, effective management and leadership. It is the result of actions, not words.
Most of the fireline firefighters are seasonal employees. What is the best way to organize, train, and acculturate them for the future benefit of both them and the fire community? There may be real benefits to bringing them on two weeks before the start of the fire season to foster safety training and cohesion. Currently, most recognition goes to permanent employees. More recognition of seasonal employees and their value to the program is needed. Better incentives for seasonal workers would promote safety and learning.
Organizational defensive behaviors are leading to unsafe practices. When investigation teams or managers cover up the causes of accidents and near misses, no learning takes place for the individuals or the organization. There is a need for forthright information and open discussion at all levels of the fire community.
Psychologically, there is more pressure on firefighters to put the fire out than to do it safely.
There appears to be too many fire orders and watchouts. A formal content analysis study may be able to reduce these guidelines to a few key ones such as LCES (Lookouts, Communications, Escape safety zones) that then should be prioritized. If some should never be violated, no matter what the circumstances, then they should be identified. Some fire orders and many watchouts are routinely disregarded. This is necessary at times to accomplish some fireline tasks and can lead to violating orders that are not just guidelines. When an order is violated and it works out okay, this can lead to more future violations. There is a general feeling that you must violate some, but that can get you in trouble when you string them together. Need to look at all the orders, watchouts, LCES and reorganize them for maximal clarity, minimum rules with clear direction from management, then enforce them routinely. Since attitudes and rules do not always predict behaviors, who is responsible for oversight and ensuring compliance?
The agency should reorganize to support the firefighters and maximize their potential. The firefighters want to perform at a high level and need the organizational support to achieve that level. The agency has made fire suppression number one, and this needs to be changed so people are number one.
There is an agency failure to follow up to see if objectives, training, etc., actually accomplish their goals. Often management sets things in motion without any idea what effect it produces in the field. Without feedback the organization does not learn.
Fire managers, IMT's, and fire crews should periodically shut down their entire operation for a day, especially after near misses or accidents. Stop doing normal routines and reassess larger goals. Groups need to focus on what is going right and what is going wrong. What is the worst that can happen, and what can be done about it. Organizational shut downs can be valuable learning experiences.
Agencies should encourage more job swapping for one year or one fire season. Examples would be hotshot/ smokejumper or FMO/hotshot swaps. We could also have a safety officer, FMO, or dispatcher shadow a hotshot crew or be shadowed by a hotshot. This would help bring down barriers and create a true community feeling.
The long-range forecast is for a period of cooler fire seasons. This is coming at a time of accelerated skill erosion of fire personnel, fewer FTE's and declining training dollars. As prescribed burning increases tenfold, the "classroom" should be moved to the burn site. OJT needs to be incorporated into the prescribed burn process.
There is a need for more FTE's and career tracks for key firefighter supervisory personnel in order to promote better experience levels and provide a more professional nucleus for supervising seasonal hires. A shift should be made to more tenured firefighters as opposed to more FMO's and managers. Overdependence on firefighting as a collateral duty has diluted the professional firefighter base.
Type I crews should have common physical fitness requirements. Current standards are too low, and the poorer fitness levels of a few are compromising the safety of the rest of the crew. This problem is especially disturbing when supervisors are less fit than their crews.

Fire Management, Incident Management Teams, and Fire Crews in a Crew Resource Management Context

Situational Awareness (Size-up)

Basic situational awareness is highly dependent upon good information, skill, and experience. It is one of the most difficult skills to master and is a weakness in the fire community.
Although basic subskills are taught in various classroom courses, little is done to see if the overall skill has transferred to the fireground.
Most firefighters possessing situational awareness demonstrate declining performance as the fire accelerates. This indicates a need for simulation training in faster paced decision making, to facilitate quick size-ups that keep pace with the fires.
With lower tempo fire situations, we have better recall and use rational processes for assessing our situation. With high tempos, rational processes are too slow. We need recognition primed decision (RPD) skills that come primarily through years of experience.
The focus here is more on sensemaking than decision making. Sensemaking (Weick 1995) is observing or creating patterns as we experience reality. These conceptual expectations form the basis to comprehend, explain, attribute, and predict events. It is experience driven rather than a logical decision process. When expectations are disconfirmed an ongoing activity is disrupted and then sensemaking is the process of coping with interruptions and surprises. It is the process of making things sensible.
During OJT, situational awareness needs to be an expected, formal action and made public to others or written down. Then feedback should be used to compare predicted versus actual results to improve predictive skills. Otherwise, we tend to revise our past predictions to fit what actually happened. This latter process actually makes us worse at predicting future events. Later, under high-tempo conditions, this skill will be fluid and rapid.
Part of the process of understanding situational awareness is to ask what are the adverse effects of incorrect size-ups.
Does the local FMO or dispatcher accept your size-up? Do they give you all the resources you order? Are the resources timely? How does your situational awareness compare to theirs? Do they advise you of resource status, recommend alternatives, and assess consequences?
Situational awareness is critical for making decisions on whether or not to fight the fire and later on whether to stay engaged or disengage from the fire.
The higher the tempo the more often you need to perform another situational check.
When any significant event changes, then another situational check must be made. When situational checks become too frequent, this is a cue to consider disengaging.
Whenever you become unsure of your situational assessment and vacillate over various inputs then "safety first" directs you to assume the worst because people tend to underestimate the severity of situations. For example, if you are vacillating between whether the situation is severe enough to order retardant, then order the retardant.
Part of situational awareness is to have a clear understanding when you are getting in over your head, when the situation no longer makes sense. Then it is time to call for more resources or to pull out.
There should be a requirement to communicate revised size-ups among crews, FMO's, and dispatch every "x" hours, depending on fire danger and time of day.
Identify situations requiring heightened awareness such as extended initial attack, transitions, interims until resources arrive, urban interface, the actual arrival of the resource, and interims after accidents or near misses.
May need a checklist of factors to consider when sizing up a situation so no factor is missed. As a minimum, LCES should be included. Discuss emergencies, what are the early warning signs and what to do if they occur.
Part of situational awareness should include giving good briefings and debriefings that communicate all the essential facts. This becomes the basis for the situational awareness of other firefighters. There should be standard briefing practices that are given and expected. Briefings should be face-to-face whenever possible. Ask questions to see if the essential content of the briefing has been understood.
A pre-accident situational awareness would be to run through all known and suspected risks associated with a fire. This initial information becomes a checklist to consider once you get to the fire.
Need a good sense of time. How long do certain actions take, how long until resources arrive, and how long to shadow during transitions?
Situational awareness cannot be mandated. We need people to be thinking, discussing, and observing constantly for most effective use of this skill.
Consider using the Campbell danger rating system or one like it for formalizing situational awareness and the language to communicate it to others. Need a system that teaches inexperienced firefighters to size up fires the way experts do. The same system should be used by the Incident Commander (IC), FMO, and dispatch for maximal information transfer.
Part of situational awareness is knowledge of safety and deployment zones, escape routes, and escape time. This must be planned and communicated to all firefighters. Emergency actions must be well practiced and understood for them to be available and effective when needed.
Situational awareness should include the fire, other people and resources, and a periodic internal check, and how all these interrelate over time.
What are situational awareness red flags?
- Change—large, unexpected, faster rate
- Expectations not met—resource changes, times
- People not communicating
- Stress—various stresses are additive
FMO's at the district, forest, or area level must develop clear criteria for determining when they are in severe or extreme fire danger. Then they must warn against business as usual and function in a high-tempo mode. They must communicate the situation to local and nonlocal fire personnel.
Dispatchers, FMO's, coordination, and resource allocation centers must develop clear criteria for determining when they are in over their heads and then call for help. The process and criteria must be in place before the need, then reviewed weekly or daily as the fire season progresses.
It is useful to project a likely situation and a worst plausible situation, then build a plan that can survive the worst plausible situation and can also work effectively for the likely situation.
Judgment of safety margins, patterns of cues that signal that risk is too high, must be carefully trained before the assignment is accepted or crews deployed. It is easier to avoid than get out of a bad situation. The judgment can be refined to reflect changing conditions to determine when the safety margin has been gradually reduced to a point where it is unacceptable. Gradual reductions are particularly difficult to observe.
Training should ensure breakpoints are overlearned for improved safety. Breakpoints involve the rapid recognition that the situation has become untenable and, rather than cope and adjust, it is time to radically change the game plan; survival has become the number one priority. This includes learning to abandon firelines that were built at considerable cost of effort.

Mission Analysis

Mission analysis begins with overall fire strategies and tactics, situational awareness with size-ups and briefings. Then the larger tactics are broken down into specific tasks, task assignments are made, tasks are monitored, then tactics reassessed.
Mission analysis tends to work well except for extended initial attack and transitions, and during interims before resources arrive, etc. In these situations environmental changes are occurring faster than strategies, tactics, and tasks can be changed to try to keep the mission on track.
Mission analysis also includes awareness and knowledge of when the mission can no longer be accomplished safely. Do not start, or disengage as appropriate.
It is crucial for overall mission success to explain the mission to the crew, explain their individual parts, then allow them a chance to ask questions and clarify the mission. It involves both briefings and debriefings. End of mission debriefings are important learning processes for transferring knowledge and learning.
Mission analysis must take into account LCES and be ready to implement alternate plans when current plans fail. Complications occur with mixed resources, indefinite resource arrival times, and unexpected fire behavior.
Each team member must have appropriate training and knowledge to accomplish a specific task. Mission analysis must clarify roles and ensure each person performs a role, yet interacts well with people or crews they border. When the mission changes, the people may need to make role changes quickly. The more risk or faster the tempo, the more supervisors must pay less attention to specific work tasks and more attention to the big picture and oversight supervision. At some point everyone must switch to emergency roles where escape becomes paramount and all individuals stop ordinary actions and focus on supervisory orders.