1. 1 Preventing The Next Tragedy Fire A Leadership Challenge And Responsibility

2. 2 The root causal factor in entrapment fatality fires directly relates to leadership at all levels of the organization! The next entrapment is entirely preventable and totally unacceptable. Does leadership have the will to change?

3. 3 Purpose Of This Presentation Present the case that leadership is the key to creating an organization that knows that things are done right, and improves performance every year Present some early thinking on how to make the transformation from an assuming to a learning organization Make some suggestions for the next steps

4. 4 A Few Qualifiers We have a great fire management organization. Comments and thoughts are only intended to make it even better When the word leadership is used, it refers to the work of leaders from firefighter to chief The most important work of leadership is to translate intent into action, and to set an organizational climate where firefighters are consistently improving performance and meeting expectations

5. 5 The case for change. Premise: If our organization was improving every year, the probability of fatalities and serious accidents would be low and getting lower every year.

6. 6 Current Expectations Referenced In Chief’s letter 10/29/01 We must take a proactive, inclusive approach in designing work projects and activities, and in developing supporting policies and procedures to ensure that our employees are never in “ harms way. ” In the Forest Service, safety is more than just a word. Safety is: “ The Relentless Pursuit of Employee Protection ” …… ensure zero tolerance for placing employees at (unmitigated) risk ….

7. 7 Current System Relies On Assumptions Assume expectations are followed National Expectations Regional Expectations Forest Expectations District Expectations Incident Expectations Current System Bad Outcomes Bad Outcomes Bad Outcomes Bad Outcomes Accountability for:Feedback Control System: Bad Outcomes Individual Expectations Assume expectations are followed

8. 8 Desired System Relies On Knowing Expectations Are Met Monitor to ensure expectations are met National Expectations Regional Expectations Forest Expectations District Expectations Incident Expectations Desired System Monitor to ensure expectations are met Meeting Expectations Meeting Expectations Meeting Expectations Meeting Expectations Accountability for:Feedback Control System: Meeting Expectations Individual Expectations Monitor to ensure expectations are met

9. 9 Two Safety Cultures An Assuming CultureA Learning Culture Communicate expectationsCommunicate, demonstrate, and model expectations Assume that expectations will be followed Check to see that expectations are being followed, and hold people accountable When things go wrong, place the blame, fix the problem, and move on When things go wrong, learn, modify, and make sure it does not happen again Surprised by the unexpectedReady for the unexpected Accidents will happenLearn how to prevent

10. 10 Current Organizational Reality Three entrapment fatality fires over the last ten years have killed 20 employees Many employees believe that fire management work is hazardous by nature, and its just a matter of time before another fatality occurs All entrapment fatalities to date have been preventable, and share the same basic causal factors Leadership has started holding fire managers and line officers accountable for bad outcomes instead of holding them accountable to meet expectations all along Fire managers are uncertain about personal risk and accountability when critical mistakes are made

11. 11 Common Causal Factors for Entrapment Fatality Fires South Canyon, Thirty Mile, and Cramer fatality fires had two general causal factors in common: –Inadequate organizational oversight –Human error

12. 12 Inadequate Organizational Oversight Leadership failed to create an organizational climate where expectations were routinely followed Organizational oversight failed to prevent, recognize, or correct critical errors before entrapment All three of the units were experienced and recognized as competent fire management organizations, and viewed these incidents as routine

13. 13 Human Error All of the last three entrapment fatality fires resulted directly from Incident Commander decision errors, and failures to follow established practices and procedures The errors were made by fire managers that were qualified and experienced In all three of these tragedy fires incident personnel considered the task at hand to be routine

14. 14 Other Important Commonalities Thresholds of predisposing risk had been exceeded, and leaders/managers/firefighters did not change strategy What had become routine strategy during low to moderate risk incidents failed when the unexpected, high-risk fire blowup occurred

15. 15 Failure To Adjust Strategies As Risk Increase Can Lead To Tragedy Risk Level Time Risk Profile of Implemented strategy High Risk Zone! Incident Maximum Potential Risk Profile Death Zone! Maximum Acceptable Risk Level Extreme Risk Level

16. 16 Altering Strategies As Risk Changes Contains Hazards Risk Level Time Risk Profile of Implemented strategy High Risk Zone! Incident Maximum Potential Risk Profile Death Zone! Maximum Acceptable Risk Level Extreme Risk Level

17. 17 Critical Hazards Even very experienced fire managers will periodically make critical errors that, if uncorrected in high-risk situations, can lead to entrapments and fatalities. This is a hazard that must be anticipated and mitigated Organizational oversight should function as an absolutely essential failsafe before and during an incident, and is the primary responsibility of leadership at all levels. Failure of oversight leaves firefighters exposed to human error in complex and high-risk situations.

18. 18 It’s Time To Change! “The definition of insanity is doing the same thing over and over again, and expecting a different result.” Albert Einstein The problem is not the people, policy, procedures, or practices. Rather the problem is leadership at all levels has not redeemed the responsibility to monitor and set a climate that ensures employees will: –Make the right decisions and follow expectations –Alter strategy as risk changes –Prevent or correct errors before they lead to tragedy

19. 19 Desirable Future An organization that: –Focuses continually on improving performance to meet expectations and, as a result, achieves increasingly better outcomes –Has a lower probability of a serious accident every year –Holds individuals accountable for meeting expectations, and, as long as they do, stands by them if things go wrong –Has a culture that acts and believes all accidents are preventable –Has systems in place that mitigate the hazard of human error

20. 20 Strategy For Creating The Desirable Future: Transform the organization by developing and implementing quality assurance systems.

21. 21 What is success? Individual Performance Effective Operations Effective Organization Success = + + Effective Organization Individual Performance Effective Operations Success Success is completing operations effectively, and having a low probability of serious accidents or fatalities that lowers every year as the organization develops!

22. 22 Quality Assurance Systems Individual Performance Effective Operations Effective Organization Success = + + Quality Assurance Systems In A Learning Culture Context Relentless pursuit of quality will lead Fire and Aviation Management to become a learning organization!

23. 23

24. 24 Ensuring An Effective Organization Effective leadership Well stated and clear objectives (Commanders Intent) Commonly held values & principles Standard operating procedures and effective training Bias for action Ability to manage the unexpected Upper level monitoring and internal reporting of hazards Feedback control system Accountable Site certification for wildland and prescribed fire operations

25. 25 Effective Organization Feedback Control Loop Effective Organization Getting & keeping effective people Training Incident Simulations Experience with incidents After action review and action plans to improve Readiness Reviews & Leadership decision simulations Site audit & certification & de-certification Feedback Control Loop Organizing for Effectiveness Line Officer Incident Performance Review

26. 26 Site Audit & Certification Primary aim is to certify line officer units at all levels for wildland and prescribed fire operations Each line officer (National, Regional, Forest, District) would clearly understand expectations for fire management performance and safety, and would periodically receive an audit to certify that systems are in place to ensure they are being met Audit results would determine if a unit was certified, under special monitoring status, or decertified

27. 27 How do we ensure individual performance? An effective individual must: –Have shared values and objectives –Receive effective growth-based education and training –Have the proper qualifications and experience for the tasks assigned –Meet currency standards –Have the opportunity to practice between incidents –Receive effective individual feedback, and a comprehensive development plan –Be evaluated and certified to meet the expectations management has of his/her performance

28. 28 Individual Performance Feedback Control Loop Effective Individual Training Incident Experience Simulation Experience Performance Improvement Plan Performance Evaluation Audit & Certification & De-Certification Feedback Control Loop

29. 29 How do we ensure effective operations? By ensuring the ten standard orders are followed By ensuring the eighteen situations are mitigated By ensuring operational strategy and tactics shift as risk changes By implementing an expert system to assist in risk assessment and monitoring By performing real time, on-site monitoring By developing and implementing continuous improvement plans

30. 30 Safe Operations Feedback Control Loop Safely Completed Operation Effective Organization Effective Individuals Ignition Detection Fire Operations Decision Support System Size Up Response Strategy Adjust Tactics as Risk Changes After Action Plan For Improvement MonitorOperations Evaluation Feedback Control Loop

31. 31 Fire Operations Decision Support System Utilizes rule-based expert system technology to monitor and advise line officers and incident commanders during wildland and prescribed fire operations Aim is to improve decision-making and ensure safe, cost- effective operations

32. 32 Fire Operations Decision Support System System Inputs –Forest Fire Plan –Weather – current & predicted –Fuels –Topography –Fire behavior – current & predicted –Local Situation, Staffing and expected resources –Predisposing thresholds of fire risk System Function –Maintained by “air traffic controllers (collision avoidance system i.e. entrapment avoidance system )” – IC relay info to dispatch –Real time risk assessment & forecast –Suggested strategies based on forest fire plan and real time conditions –Map/name of potential incidents requiring intense monitoring due to current extreme risk OR predicted risk

33. 33 Decision Support Concept

34. 34 The Decision Path Is Critical To Safety AND Cost Containment! Incident Decision Path Detection Initial Attack Dispatch Size Up Fire Operations Decision Support System Extended Initial Attack Type II IncidentType I Incident Controlled Transition Mega-Fire Real Time Risk Assessments Automated WFSA Support Information Mega Fire Model and Cost Containment Strategies Flags Incidents That Are Classified As Extreme Risk

35. 35 Fire Operations Decision Support System Consider implementing this system as a module of FPA System will be used to help manage risk in wildland and prescribed fire operations System will be used to help in cost containment and managing mega-fires System information will be used for after action reviews at all scales

36. 36 Strategies For Success Implement feedback control mechanisms for ensuring success. –Short Term: Implementing Cramer ARB action plan will serve to create a feedback control loop for ensuring effective Type III ICs –Intermediate Term: Implementing a certification system for line officer units will serve to ensure safe, effective organizations –Long Term: Implementing a fire decision support system will serve to ensure safe, effective operations

37. 37 Assumptions Lead To Tragedy About 2% of the time routine practice is not enough to keep firefighters out of extreme danger. About 1% of the time that firefighters are in extreme danger, luck runs out and leads to death!

38. 38 To Prevent Tragedy We must replace assumptions with monitoring and improvement to stop that last 2% of critical errors from occurring.

39. 39 Hazard Defense System Potential Losses LEADERSHIPLEADERSHIP POL/PRA/PROPOL/PRA/PRO TRAININGTRAINING MONITORINGMONITORING Hazards IPROVEMENTIPROVEMENT A risk management system that continually improves in performance is an impenetrable containment for hazards.

40. 40 Discussion No leadership action or inaction is worth a life lost. What is leadership going to do to prevent the next tragedy fire?