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

Findings From the Wildland Firefighters Human Factors Workshop

Appendix E—Related Reports

The Collapse of Sensemaking in Organizations:
The Mann Gulch Disaster

Karl E. Weick . Reprinted from The Collapse of Sensemaking in Organizations: The Mann Gulch Disaster by Karl E. Weick published in Administrative Science Quarterly Volume 38 (1993): 628-652 by permission of Administrative Science Quarterly. © 1993 by Cornell University 0001-8392/93/3804-0628.

This is a revised version of the Katz- Newcomb lecture presented at the University of Michigan, April 23-24, 1993. The 1993 lecture celebrated the life of Rensis Likert, the founding director of the Institute for Social Relations. All three people honored at the lecture—Dan Katz, Ted Newcomb, and Ren Likert—were born in 1903, which meant this lecture also celebrated their 90th birthdays. I am grateful to Lance Sandelands, Debra Meyerson, Robert Sutton, Doug Cowherd, and Karen Weick for their help in revising early drafts of this material. I also want to thank John Van Maanen, J. Richard Hackman, Linda Pike, and the anonymous ASQ reviewers for their help with later drafts.

The death of 13 men in the Mann Gulch fire disaster, made famous in Norman Maclean's Young Men and Fire, is analyzed as the interactive disintegration of role structure and sensemaking in a minimal organization. Four potential sources of resilience that make groups less vulnerable to disruptions of sensemaking are proposed to forestall disintegration, including improvisation, virtual role systems, the attitude of wisdom, and norms of respectful interaction. The analysis is then embedded in the organizational literature to show that we need to reexamine our thinking about temporary systems, structuration, nondisclosive intimacy, intergroup dynamics, and team building.

The purpose of this article is to reanalyze the Mann Gulch fire disaster in Montana described in Norman Maclean's (1992) award-winning book Young Men and Fire to illustrate a gap in our current understanding of organizations. l want to focus on two questions: Why do organizations unravel? And how can organizations be made more resilient? Before doing so, however, l want to strip Maclean's elegant prose away from the events in Mann Gulch and simply review them to provide a context for the analysis.

The Incident

As Maclean puts it, at its heart, the Mann Gulch disaster is a story of a race (p. 224). The smokejumpers in the race (excluding foreman "Wag" Wagner Dodge and ranger Jim Harrison) were ages 17-28, unmarried, seven of them were forestry students (p. 27), and 12 of them had seen military service (p. 220). They were a highly select group (p. 27) and often described themselves as professional adventurers (p. 26). A lightning storm passed over the Mann Gulch area at 4 p.m. on August 4, 1949 and is believed to have set a small fire in a dead tree. The next day, August 5, 1949, the temperature was 97 degrees and the fire danger rating was 74 out of a possible 100 (p. 42), which means " explosive potential" (p. 79). When the fire was spotted by a forest ranger, the smokejumpers were dispatched to fight it. Sixteen of them flew out of Missoula, Montana at 2:30 p.m. in a C-47 transport. Wind conditions that day were turbulent, and one smokejumper got sick on the airplane, didn't jump, returned to the base with the plane, and resigned from the smokejumpers as soon as he landed ("his repressions had caught up with him," p. 51). The smokejumpers and their cargo were dropped on the south side of Mann Gulch at 4:10 p.m. from 2000 feet rather than the normal 1200 feet, due to the turbulence (p. 48). The parachute that was connected to their radio failed to open, and the radio was pulverized when it hit the ground. The crew met ranger Jim Harrison who had been fighting the fire alone for four hours (p. 62), collected their supplies, and ate supper. About 5:10 p.m. (p. 57) they started to move along the south side of the gulch to surround the fire (p. 62). Dodge and Harrison, however, having scouted ahead, were worried that the thick forest near which they had landed might be a "death trap" (p. 64). They told the second in command, William Hellman, to take the crew across to the north side of the gulch and march them toward the river along the side of the hill. While Hellman did this, Dodge and Harrison ate a quick meal. Dodge rejoined the crew at 5:40 p.m. and took his position at the head of the line moving toward the river. He could see flames flapping back and forth on the south slope as he looked to his left (p. 69).

At this point the reader hits the most chilling sentence in the entire book: " Then Dodge saw it!" (p. 70). What he saw was that the fire had crossed the gulch just 200 yards ahead and was moving toward them (p. 70). Dodge turned the crew around and had them angle up the 76-percent hill toward the ridge at the top (p. 175). They were soon moving through bunch grass that was two and a half feet tall and were quickly losing ground to the 30-foot-high flames that were soon moving toward them at 610 feet per minute (p. 274). Dodge yelled at the crew to drop their tools, and then, to everyone's astonishment, he lit a fire in front of them and ordered them to lie down in the area it had burned. No one did, and they all ran for the ridge. Two people, Sallee and Rumsey, made it through a crevice in the ridge unburned, Hellman made it over the ridge burned horribly and died at noon the next day, Dodge lived by lying down in the ashes of his escape fire, and one other person, Joseph Sylvia, lived for a short while and then died. The hands on Harrison's watch melted at 5:56 (p. 90), which has been treated officially as the time the 13 people died.

After the fire passed, Dodge found Sallee and Rumsey, and Rumsey stayed to care for Hellman while Sallee and Dodge hiked out for help. They walked into the Meriwether ranger station at 8:50 p.m. (p. 113), and rescue parties immediately set out to recover the dead and dying. All the dead were found in an area of 100 yards by 300 yards (p. 111). It took 450 men five more days to get the 4,500-acre Mann Gulch fire under control (pp. 24, 33). At the time the crew jumped on the fire, it was classified as a Class C fire, meaning its scope was between 10 and 99 acres.

The Forest Service inquiry held after the fire, judged by many to be inadequate, concluded that "there is no evidence of disregard by those responsible for the jumper crew of the elements of risk which they are expected to take into account in placing jumper crews on fires." The board also felt that the men would have been saved had they " heeded Dodge's efforts to get them to go into the escape fire area with him" (quoted in Maclean, p. 151). Several parents brought suit against the Forest Service, claiming that people should not have been jumped in the first place (p. 149), but these claims were dismissed by the Ninth Circuit U.S. Court of Appeals, where Warren E. Burger argued the Forest Service's case (p. 151).

Since Mann Gulch, there have been no deaths by burning among Forest Service firefighters, and people are now equipped with backup radios (p. 219), better physical conditioning, the tactic of building an escape fire, knowledge that fires in timber west of the Continental Divide burn differently than do fires in grass east of the Divide, and the insistence that crew safety take precedence over fire suppression.

The Methodology

Among the sources of evidence Maclean used to construct this case study were interviews, trace records, archival records, direct observation, personal experience, and mathematical models.

Since Maclean did not begin to gather documents on Mann Gulch until 1976 (p. 156) and did not start to work in earnest on this project until his seventy-fourth birthday in 1977, the lapse of almost 28 years since the disaster made interviewing difficult, especially since Dodge had died of Hodgkin's disease five years after the fire (p. 106). Maclean located and interviewed both living witnesses of the blaze, Sallee and Rumsey, and persuaded both to accompany him and Laird Robinson, a guide at the smokejumper base, on a visit back to the site on July 1, 1978. Maclean also knew Dodge's wife and had talked to her informally (p. 40). He attempted to interview relatives of some who lost their lives but found them too distraught 27 years later to be of much help (p. 154). He also attempted to interview (p. 239) a member of the Forest Service inquiry team, A. J. Cramer who, in 1951, had persuaded Sallee, Rumsey, and ranger Robert Jansson to alter their testimony about the timing of key incidents. Cramer was the custodian of seven or eight watches that had been removed from victims (p. 233), only one of which (Harrison's) was released and used as the official time of the disaster (5:56 p.m.). To this day it remains unclear why the Forest Service made such a strong effort to locate the disaster closer to 6:00 p.m. than to 5:30, which was suggested by testimony from Jansson, who was near the river when the fire blew up, and from a recovered watch that read 5:42. Maclean had continuing access to two Forest Service insiders, Bud Moore and Laird Robinson (p. 162). He also interviewed experts on precedents for the escape fire (p. 104) and on the nature of death by fire (p. 213).

The use of trace records, or physical evidence of past behaviors, is illustrated by the location during a 1979 trip to the gulch, of the wooden cross that had been placed in 1949 to mark the spot where Dodge lit his escape fire (p. 206). The year before, 1978, during the trip into the gulch with Sallee and Rumsey, Maclean located the rusty can of potatoes that had been discarded after Hellman drank its salty water through two knife slits Rumsey had made in the can (p. 173). He also located the flat rocks on which Hellman and Sylvia had rested while awaiting rescue, the juniper tree that was just beyond the crevice Sallee and Rumsey squeezed through on the ridge (p. 207), and Henry Thol, Jr.'s flashlight (p. 183). Considering the lapse of time, the destructive forces of nature over 28 years, and the power of a blowup fire to melt and displace everything in its path, discovery of these traces is surprising as well as helpful in reconstructing events.

Archival records are crucial to the development of the case, although the Forest Service made a considerable effort after its inquiry to scatter the documents (p. 153) and to classify most of them "Confidential" (p. 158), perhaps fearing it would be charged with negligence. Records used by Maclean included statistical reports of fire suppression by smokejumpers in Forest Service Region 1 (e.g., p. 24); the report of the Forest Service Board of Review issued shortly after the incident (dated September 29, 1949, which many felt was too soon for the board to do an adequate job); statements made to the board by people such as the C-47 pilot, parents of the dead crew (p. 150), and the spotter on the aircraft (p. 42); court reports of litigation brought by parents of smokejumpers against the Forest Service; photographs, virtually all of which were retrieved for him by women in the Forest Service who were eager to help him tell the story (p. 160); early records of the smokejumpers organization, which was nine years old at the time of the disaster; reports of the 1957 task force on crew safety (p. 221); and contemporary reports of the disaster in the media, such as the report in the August 22, 1949 issue of Life magazine.

Direct observation occurred during Maclean's three visits to Mann Gulch in 1976, 1977, and 1978 (p. 189), trips made much more difficult because of the inaccessibility of the area (pp. 191-192). The most important of these three visits is the trip to the gulch with Sallee and Rumsey, during which the latter pair reenacted what they did and what they saw intermittently through the dense smoke. When their accounts were matched against subsequent hard data (e.g., their estimation of where Dodge lit his escape fire compared against discovery of the actual cross planted in 1949 to mark the spot), it was found that their reconstruction of events prior to the time they made it to safety through the crevice is less accurate than their memory for events and locations after they made it to safety. This suggests to Maclean that "we don't remember as exactly the desperate moments when our lives are in the balance as we remember the moments after, when the balance has tipped in our favor" (p. 212). Direct observation also occurred when Maclean and Robinson themselves hiked the steep slopes of Mann Gulch under summer conditions of heat and slippery, tall grass that resembled the conditions present in the disaster of 1949. The two men repeatedly compared photos and maps from 1949 with physical outcroppings in front of them to see more clearly what they were looking at (e.g., photos misrepresent the steepness of the slope, p. 175). There were also informal experiments, as when Rod Norum, an athlete and specialist on fire behavior, retraced Dodge's route from the point at which he rejoined the crew, moved as fast as possible over the route Dodge covered, and was unable to reach the grave markers as fast as the crew did (p. 67). During these trips, Maclean took special note of prevailing winds by observing their effect on the direction in which rotted timber fell. These observations were used to build a theory of how wind currents in the gulch could have produced the blowup (p. 133).

Personal experience was part of the case because, in 1949, Maclean had visited the Mann Gulch fire while it was still burning (p. 1). Maclean also was a Forest Service firefighter (not a smokejumper) at age 15 and nearly lost his life in the Fish Creek fire, a fire much like the one in Mann Gulch (p. 4). Maclean also reports using his practical experience as a woodsman to suggest initial hypotheses regarding what happened at Mann Gulch (e.g., he infers wind patterns in the gulch from observations of unusual wave action in the adjacent Missouri River, p. 131).

Having collected data using the above sources, but still feeling gaps in his understanding of precisely how the race between fire and men unfolded, Maclean taught himself mathematics and turned to mathematical modeling. He worked with two mathematicians, Frank Albini and Richard Rothermel, who had built mathematical models of how fires spread. The group ran the predictive models in reverse to see what the fire in Mann Gulch must have been like to generate the reports on its progress that were found in interviews, reports, and actual measurements. It is the combination of output from the model and subjective reports that provide the revealing time line of the final 16 minutes (pp. 267-277).

If these several sources of evidence are combined and assessed for the adequacy with which they address " sources of invalidity," it will be found that they combat 12 of the 15 sources listed by Runkel and McGrath (1972: 191) and are only "moderately vulnerable" to the other three. Of course, an experienced woodsman and storyteller who has "always tried to be accurate with facts" (p. 259) would expect that. The rest of us in organizational studies may be pardoned, however, if we find those numbers a good reason to take these data seriously.

Cosmology Episodes in Mann Gulch

Early in the book (p. 65), Maclean asks the question on which I want to focus: " what the structure of a small outfit should be when its business is to meet sudden danger and prevent disaster." This question is timely because the work of organizations is increasingly done in small temporary outfits in which the stakes are high and where foul-ups can have serious consequences (Heydebrand, 1989; Ancona and Caldwell, 1992). Thus, if we understand what happened at Mann Gulch, we may be able to learn some valuable lessons in how to conceptualize and cope with contemporary organizations.

Let me first be clear about why I think the crew of smokejumpers at Mann Gulch was an organization. First, they have a series of interlocking routines, which is crucial in Westley's (1990: 339) definition of an organization as "a series of interlocking routines, habituated action patterns that bring the same people together around the same activities in the same time and places." The crew at Mann Gulch have routine, habituated action patterns, they come together from a common pool of people, and while this set of individual smokejumpers had not come together at the same places or times, they did come together around the same episodes of fire. Westley's definition suggests it doesn't take much to qualify as an organization. The other side is, it also may not take much to stop being one.

Second, the Mann Gulch crew fits the five criteria for a simple organizational structure proposed by Mintzberg (1983: 158). These five include coordination by direct supervision, strategy planned at the top, little formalized behavior, organic structure, and the person in charge tending to formulate plans intuitively, meaning that the plans are generally a direct "extension of his own personality." Structures like this are found most often in entrepreneurial firms.

And third, the Mann Gulch crew has " generic subjectivity" (Wiley, 1988), meaning that roles and rules exist that enable individuals to be interchanged with little disruption to the ongoing pattern of interaction. In the crew at Mann Gulch there were at least three roles: leader, second in command, and crewmember. The person in the lead sizes up the situation, makes decisions, yells orders, picks trails, sets the pace, and identifies escape routes (pp. 65-66). The second in command brings up the rear of the crew as it hikes, repeats orders, sees that the orders are understood, helps the individuals coordinate their actions, and tends to be closer to the crew and more of a buddy with them than does the leader. And finally, the crew clears a fire line around the fire, cleans up after the fire, and maintains trails. Thus, the crew at Mann Gulch is an organization by virtue of a role structure of interlocking routines.

I want to argue that the tragedy at Mann Gulch alerts us to an unsuspected source of vulnerability in organizations. Minimal organizations, such as we find in the crew at Mann Gulch, are susceptible to sudden losses of meaning, which have been variously described as fundamental surprises (Reason, 1990) or events that are inconceivable (Lanir, 1989), hidden (Westrum, 1982), or incomprehensible (Perrow, 1984). Each of these labels points to the low probability that the event could occur, which is why it is meaningless. But these explanations say less about the astonishment of the perceiver and even less about the perceiver's inability to rebuild some sense of what is happening.

To shift the analytic focus in implausible events from probabilities to feelings and social construction, l have borrowed the term "cosmology" from philosophy and stretched it. Cosmology refers to a branch of philosophy often subsumedunder metaphysics that combines rational speculation and scientific evidence to understand the universe as a totality of phenomena. Cosmology is the ultimate macro perspective, directed at issues of time, space, change, and contingency as they relate to the origin and structure of the universe. Integrations of these issues, however, are not just the handiwork of philosophers. Others also make their peace with these issues, as reflected in what they take for granted. People, including those who are smokejumpers, act as if events cohere in time and space and that change unfolds in an orderly manner. These everyday cosmologies are subject to disruption. And when they are severely disrupted, l call this a cosmology episode (Weick, 1985: 51-52). A cosmology episode occurs when people suddenly and deeply feel that the universe is no longer a rational, orderly system. What makes such an episode so shattering is that both the sense of what is occurring and the means to rebuild that sense collapse together.

Stated more informally, a cosmology episode feels like vu jàdé—the opposite of déjà vu: I've never been here before, l have no idea where I am, and I have no idea who can help me. This is what the smokejumpers may have felt increasingly as the afternoon wore on and they lost what little organization structure they had to start with. As they lost structure they became more anxious and found it harder to make sense of what was happening, until they finally were unable to make any sense whatsoever of the one thing that would have saved their lives, an escape fire. The disaster at Mann Gulch was produced by the interrelated collapse of sensemaking and structure. If we can understand this collapse, we may be able to forestall similar disasters in other organizations.

Sensemaking in Mann Gulch

Although most organizational analyses begin and end with decision making, there is growing dissatisfaction with this orthodoxy. Reed (1991) showed how far the concept of decision making has been stretched, singling out the patching that James G. March has done in recent discussions of decision making. March (1989: 14) wrote that "decision making is a highly contextual, sacred activity, surrounded by myth and ritual, and as much concerned with the interpretive order as with the specifics of particular choices." Reed (1991: 561) summarized March this way: "decision making preferences are often inconsistent, unstable, and externally driven; the linkages between decisions and actions are loosely-coupled and interactive rather than linear; the past is notoriously unreliable as a guide to the present or the future; and…political and symbolic considerations play a central, perhaps overriding, role in decision making." Reed wondered aloud whether, if March is right in these descriptions, decision making should continue to set the agenda for organizational studies. At some point a retreat from classic principles becomes a rout.

There have been at least three distinct responses to these problems. First, there has been a shift, reminiscent of Neisser and Winograd's (1988) work on memory, toward examining naturalistic decision making (Orasanu and Connolly, 1993), with more attention to situational assessment and sensemaking (Klein, 1993). Second, people have replaced an interest in decision making with an interest in power, noting, for example, that "power is most strategically deployed in the design and implementation of paradigmatic frameworks within which the very meaning of such actions as ' making decisions' is defined" (Brown, 1978: 376). And third, people are replacing the less appropriate normative models of rationality (e.g., Hirsch, Michaels, and Friedman, 1987) based on asocial "economic man" (Beach and Lipshitz, 1993) with more appropriate models of rationality that are more sophisticated about social relations, such as the model of contextual rationality (White, 1988).

Reed (1991) described contextual rationality as action motivated to create and maintain institutions and traditions that express some conception of right behavior and a good life with others. Contextual rationality is sensitive to the fact that social actors need to create and maintain intersubjectively binding normative structures that sustain and enrich their relationships. Thus, organizations become important because they can provide meaning and order in the face of environments that impose ill defined, contradictory demands.

One way to shift the focus from decision making to meaning is to look more closely at sensemaking in organizations. The basic idea of sensemaking is that reality is an ongoing accomplishment that emerges from efforts to create order and make retrospective sense of what occurs. Recognition-primed decision making, a model based in part on command decisions made by firefighters, has features of sensemaking in its reliance on past experience, although it remains grounded in decision making (Klein, 1993). Sensemaking emphasizes that people try to make things rationally accountable to themselves and others. Thus, in the words of Morgan, Frost, and Pondy (1983: 24), "individuals are not seen as living in, and acting out their lives in relation to, a wider reality, so much as creating and sustaining images of a wider reality, in part to rationalize what they are doing. They realize their reality, by reading into their situation patterns of significant meaning."

When the smokejumpers landed at Mann Gulch, they expected to find what they had come to call a 10:00 fire. A 10:00 fire is one that can be surrounded completely and isolated by 10:00 the next morning. The spotters on the aircraft that carried the smokejumpers " figured the crew would have it under control by 10:00 the next morning" (Maclean, p. 43). People rationalized this image until it was too late. And because they did, less and less of what they saw made sense:

The crew expects a 10:00 fire but grows uneasy when this fire does not act like one.
Crewmembers wonder how this fire can be all that serious if Dodge and Harrison eat supper while they hike toward the river.
People are often unclear who is in charge of the crew (p. 65).
The flames on the south side of the gulch look intense, yet one of the smokejumpers, David Navon is taking pictures, so people conclude the fire can't be that serious, even though their senses tell them otherwise.
Crewmembers know they are moving toward the river where they will be safe from the fire, only to see Dodge inexplicably turn them around, away from the river, and start angling upslope, but not running straight for the top. Why? (Dodge is the only one who sees the fire jump the gulch ahead of them.)
As the fire gains on them, Dodge says, " Drop your tools," but if the people in the crew do that, then who are they? Firefighters? With no tools?
The foreman lights a fire that seems to be right in the middle of the only escape route people can see.
The foreman points to the fire he has started and yells, "Join me," whatever that means. But his second in command sounds like he's saying, "To hell with that, I'm getting out of here" (p. 95).
Each individual faces the dilemma, l must be my own boss yet follow orders unhesitatingly, but I can't comprehend what the orders mean, and I'm losing my race with the advancing fire (pp. 219-220).

As Mann Gulch loses its resemblance to a 10:00 fire, it does so in ways that make it increasingly hard to socially construct reality. When the noise created by wind, flames, and exploding trees is deafening; when people are strung out in a line and relative strangers to begin with; when they are people who, in Maclean's words, " love the universe but are not intimidated by it" (p. 28); and when the temperature is approaching a lethal 140 degrees (p. 220), people can neither validate their impressions with a trusted neighbor nor pay close attention to a boss who is also unknown and whose commands make no sense whatsoever. As if these were not obstacles enough, it is hard to make common sense when each person sees something different or nothing at all because of the smoke.

The crew's stubborn belief that it faced a 10:00 fire is a powerful reminder that positive illusions (Taylor, 1989) can kill people. But the more general point is that organizations can be good at decision making and still falter. They falter because of deficient sensemaking. The world of decision making is about strategic rationality. It is built from clear questions and clear answers that attempt to remove ignorance (Daft and Macintosh, 1981). The world of sensemaking is different. Sensemaking is about contextual rationality. It is built out of vague questions, muddy answers, and negotiated agreements that attempt to reduce confusion. People in Mann Gulch did not face questions like where should we go, when do we take a stand, or what should our strategy be? Instead, they faced the more basic, the more frightening feeling that their old labels were no longer working. They were outstripping their past experience and were not sure either what was up or who they were. Until they develop some sense of issues like this, there is nothing to decide.

Role Structure in Mann Gulch

Sensemaking was not the only problem in Mann Gulch. There were also problems of structure. It seems plausible to argue that a major contributor to this disaster was the loss of the only structure that kept these people organized, their role system. There were two key events that destroyed the organization that tied these people together. First, when Dodge told Hellman to take the crew to the north side of the gulch and have it follow a contour down toward the river, the crew got confused, the spaces between members widened appreciably, and Navon—the person taking pictures (p. 71)— made a bid to take over the leadership of the group (p. 65). Notice what this does to the role system. There is now no one at the end of the line repeating orders as a check on the accuracy with which they are understood. Furthermore, the person who is leading them, Hellman, is more familiar with implementing orders than with constructing them or plotting possible escape routes. So the crew is left for a crucial period of time with ill-structured, unacknowledged orders shouted by someone who is unaccustomed to being firm or noticing escape routes. Both routines and interlocking are beginning to come apart. The second, and in some way more unsettling threat to the role system occurred when Dodge told the retreating crew "throw away your tools!" (p. 226). A fire crew that retreats from a fire should find its identity and morale strained. If the retreating people are then also told to discard the very things that are their reason for being there in the first place, then the moment quickly turns existential. If I am no longer a firefighter, then who am l? With the fire bearing down, the only possible answer becomes, An endangered person in a world where it is every man for himself. Thus, people who, in Maclean's words, had perpetually been almost their own boss (p. 218) suddenly became completely their own boss at the worst possible moment. As the entity of a crew dissolved, it is not surprising that the final command from the "crew" leader to jump into an escape fire was heard not as a legitimate order but as the ravings of someone who had "gone nuts" (p. 75). Dodge's command lost its basis of legitimacy when the smokejumpers threw away their organization along with their tools.

Panic In Mann Gulch

With these observations as background, we can now look more closely at the process of a cosmology episode, an interlude in which the orderliness of the universe is called into question because both understanding and procedures for sensemaking collapse together. People stop thinking and panic. What is interesting about this collapse is that it was discussed by Freud (1959: 28) in the context of panic in military groups: "A panic arises if a group of that kind [military group] becomes disintegrated. Its characteristics are that none of the orders given by superiors are any longer listened to, and that each individual is only solicitous on his own account, and without any consideration for the rest. The mutual ties have ceased to exist, and a gigantic and senseless fear is set free." Unlike earlier formulations, such as McDougall's (1920), which had argued that panic leads to group disintegration, Freud, reversing this causality, argued that group disintegration precipitates panic. By group disintegration, Freud meant "the cessation of all the feelings of consideration which the members of the group otherwise show one another" (p. 29). He described the mechanism involved this way: "If an individual in panic fear begins to be solicitous only on his own account, he bears witness in so doing to the fact that the emotional ties, which have hitherto made the danger seem small to him, have ceased to exist. Now that he is by himself in facing the danger, he may surely think it greater."

It is certainly true in Mann Gulch that there is a real, palpable danger that can be seen, felt, heard, and smelled by the smokejumpers. But this is not the first time they have confronted danger. It may, however, be the first time they have confronted danger as a member of a disintegrating organization. As the crew moved toward the river and became more spread out, individuals were isolated and left without explanations or emotional support for their reactions. As the ties weakened, the sense of danger increased, and the means to cope became more primitive. The world rapidly shifted from a cosmos to chaos as it became emptied of order and rationality.

It is intriguing that the three people who survived the disaster did so in ways that seem to forestall group disintegration. Sallee and Rumsey stuck together, their small group of two people did not disintegrate, which helped them keep their fear under control. As a result, they escaped through a crack in the ridge that the others either didn't see or thought was too small to squeeze through. Wag Dodge, as the formal leader of a group he presumed still existed, ordered his followers to join him in the escape fire. Dodge continued to see a group and to think about its well-being, which helped keep his own fear under control. The rest of the people, however, took less notice of one another. Consequently, the group, as they knew it, disintegrated. As their group disintegrated, the smokejumpers became more frightened, stopped thinking sooner, pulled apart even more, and in doing so, lost a leader-follower relationship as well as access to the novel ideas of other people who are a lot like them. As these relationships disappeared, individuals reverted to primitive tendencies of flight. Unfortunately, this response was too simple to match the complexity of the Mann Gulch fire.

What holds organization in place may be more tenuous than we realize. The recipe for disorganization in Mann Gulch is not all that rare in everyday life. The recipe reads, Thrust people into unfamiliar roles, leave some key roles unfilled, make the task more ambiguous, discredit the role system, and make all of these changes in a context in which small events can combine into something monstrous. Faced with similar conditions, organizations that seem much sturdier may also come crashing down (Miller, 1990; Miles and Snow, 1992), much like Icarus who overreached his competence as he flew toward the sun and also perished because of fire.