What does a well-founded risk decision look like?

By Mark Smith, Mission-Centered Solutions

©Mission-Centered Solutions

This paper is the result of an ongoing dialog around risk I’ve had within the post-Yarnell Honor the Fallen group. One member posed the rhetorical but critical question: “Should we be risking lives for suppression efforts or not? “That prompted my response in The Big Lie essay on the levels of risk I think wildland firefighters operate in routinely, and how we could be more intelligently accepting that risk.

I have been doing a presentation the last few years called “Luck Runs Out.”  Where “The Big Lie” was more a problem statement, “Luck Runs Out” is meant to focus on actionable, practical steps forward for IMTs and Agency Administrators.  What follows started not as an essay but just a handout to go with that presentation, so it was meant to have the context of that larger presentation, although people have told me it reads okay on its own as a stand-alone piece. See what you think!


 

The difficult truth is that wildland firefighting is a high risk-endeavor. Consider the policy that all firefighters on the line carry fire shelters. It is an overt acknowledgment that each time firefighters directly participate in a wildland fire suppression or management activity, their lives are at risk. Moreover, the wildland fire environment is exponentially increasing in complexity, magnifying the risks. What is not keeping pace, however, is our sophistication to plan, operate and support within that complex risk-filled environment. Our tools fall farther behind each fire season.

In an attempt to address this challenge, leaders often make declarations like “No structure is worth a life!” While true, the statement lacks any meaningful guidance. In contrast, it is the job of any risk professional to determine exactly what risk level the structure is worth. And while that assertion may appear straightforward, applying the concept continues to confound senior wildland fire managers.

Where does a well-founded risk decision start? First, it must always start with clearly identified and prioritized values at risk (VaR). It is the “outcome” in “does the outcome justify the risk?” It is the “gain” in “risk vs gain.” It is the “purpose” in the “task, purpose, end state” of leader’s intent.

If the prioritized values at risk are not clearly considered, articulated and displayed for all to see, all subsequent risk decisions will be deeply flawed. They must be specifically discussed in the agency administrator (AA) briefing, and reconsidered during every subsequent objectives, strategy, and tactics meetings.

Second, we must conduct a meaningful assessment of the risks firefighters might encounter. The current risk analysis (ICS Form 215a) on the NWCG website reflects a 1970’s approach to risk. One lists the risks and then mitigations for those risks. It does not quantify the risk in any way, nor is there any discussion of the risk level after mitigation and whether that residual risk is acceptable.

Given what we know about the flaws of that form, its continued use will come to be seen as negligence and opens the agencies and their practitioners to increased liability as time goes on.

In order to see the truth of the risk levels wildland firefighters operate within and evolution required to make the best risk decisions, first consider the two axis, probability/severity model. Most incident management teams (IMTs) now use a modified risk analysis (215a) incorporating this model.

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Typical Probability/Severity Model

The attraction to this model is the simplicity of its Green/Amber/Red “traffic light” appeal. Unfortunately, it is not nuanced enough for the wildland fire environment. When you really do a solid risk assessment, so much falls in places like the “low end of high” or “medium-high”. It also lacks the sophistication of accounting for exposure, such as the number of operational periods, number of fuel cycles, number of people, and so forth.

It also fails to factor in the compounding cumulative effects such as multiple hazards added upon each other. For example, Division A is in high risk because of snags and falling objects, but also because of road conditions and aviation operations. That’s not just high risk, it’s now HighRisk3.

In the exposure curve below, the mathematical reality of just how harshly the odds change as you move up that probability axis is alarming. When you compound risks or factor in exposure, such as being fatigued AND being in steep rocky terrain AND being on Day 12 of an assignment, the percentages increase exponentially.

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Compounding Exposure Curve

 

A key step forward would be adopting a more sophisticated probability/severity matrix that takes these additional factors into account and more accurately depicts the risk spectrum in the wildland fire environment.

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More Sophisticated Probability/Severity Matrix

On the severity axis — You can do a few things on the mitigation side that might influence severity. A jumper’s Kevlar suit, for example, will help when smacking into a tree, but there is good chance the jumper will still break some bones. Similarly, a fire shelter might move the consequences from being a fatality to just being a burn victim, but nonetheless, a significant risk remains.

Given the inherent dangers in the wildland fire environment, severity is always going to be high if things go bad. Given the likely consequences, most of the operations on the fireline are going to be Medium or High risk. It is extremely rare to find a fire where all operations are in the Low risk category.

So most of the decisions concerning risk have to focus on the probability axis. For good risk decisions, a model like this should be part of the AA Briefing and on the wall next to the 215A for discussion. “Should we knowingly risk lives?” –- would more appropriately be re-phrased to “Should we put people where the likelihood of something bad happening is elevated?” You can see on the matrix how quickly risk escalates when you move from Remote to Unlikely to Possible.

One of the inherent challenges in risk management is, as humans, we can’t feel when the odds go from 1 in 1,000,000 to 1 in 1,000. But the universe tracks all that perfectly in real time. This is the discussion that should be happening in front of the 215A. Not just listing the threats and mitigations of rocks, snakes and lightning, but having the dialog and knowing that the real risk is somewhere halfway between the most probable fire and the worst-case fire. Judging how likely it is for an operation to encounter that next elevated risk level and considering the conditions that might precipitate it become essential.

When things move from Unlikely to Possible that’s a big jump, and leaders must reconsider that risk/gain calculus. Unless there’s a cabin in the woods full of babies, puppies and kittens, then the answer is clearly: No, we should not be putting firefighters in a place where the likelihood is moving into the upper end of Possible and the resulting risk Extreme.

Within the wildland fire environment, risk levels are routinely going to be medium or high risk. There probably isn’t anything humans can do to avoid that. We should have very high expectations of our AA and IMT decision makers in terms of critical thinking and their sophistication in making acceptable risk decisions, which means we need tools worthy of the actual risks that firefighters are taking in the current suppression paradigm. Under that current model, we are risking lives and consequently, we have a duty to make sure it’s being done intelligently.

In military special operations, a risk must be determined as necessary during the planning process in order to accomplish an objective. “If we do this, here’s the necessary risk we’re going to have to take.” At that point, the question gets asked “Does the outcome justify that risk?” if so, that becomes the acceptable risk. If not, then you try and mitigate risk down to the acceptable level. If you can’t get it there, it’s not acceptable and military operators look for another way to accomplish that objective with lower risk. In some cases, the objective must be abandoned all together because the risk is too high relative to the outcome.

The difference in special operations is that the small unit (i.e. crew) is heavily involved in the mission planning and the risk decisions. That’s not true in wildland fire –- an echo of why we still have Great Depression/chain-gang era terms like Crew Bosses in wildland fire job descriptions. In wildland fire, risk planning, mitigation and decision-making often occur absent those who will directly encounter the risk. This places a significant responsibility on the AA and IMT staff to discuss strategic and operational risks at the Common Operating Picture (COP) meeting each day, in reviewing the planned end state, and creating (or validating) objectives based on VaR. These strategic and operational risks must be further validated and refined at the strategy and tactics meetings, where the staff flesh out the necessary risks.

Once articulated on the 215A, it is incumbent among every member of the staff to ask the question “Are the residual risks we’re left with — post-mitigation — justifiable?

No tree is worth a life” only tells you what a tree is not worth. But what is it worth? What is the acceptable risk around protecting a tree? A structure? A subdivision? Clearly, the leadership’s responsibility is to make and communicate that decision, but absent a meaningful way to make the acceptable decision, operators are often left to interpret this ambiguous intent on their own.

The shortcoming isn’t a result of the absence of concern, desire or intent, but rather the lack of the necessary tools for wildland firefighters to make any kind of objective decisions about acceptable risk. And that’s because there is nothing that maps the priority of values at risk to the acceptable risks to protect them. We want that to be very clear. Very simple.

Below is an example of what that mapping might look like. As with many examples, things are missing and you may not agree with how the VaR have been prioritized, but that’s intentional. A finished, interagency version should be clear enough so that there is no misunderstanding or disagreement. It is part of the pre-determined playbook. Pending a “Red Book” version, this is an AA and an IMT responsibility to develop and communicate to all:

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EXAMPLE of possible Acceptable Risk Guidelines

This matrix provides clear acceptable risk guidelines for a category of VaR. Incident commanders would be able to make exceptions using the same authority they have now to adjust work/rest and other guidelines, but this removes the “What is a tree worth?” ambiguity.

The challenge remains, however, that without some metrics to assign to an identified risk, the assessment is still subjective. “Hmmm… It will take 2.5 hours to get someone from Division C to the hospital if they get hurt. How do you think that effects the risk level?

Some IMTs are starting to assign some numerical values to each of the hazards and risks identified. Example: “Under 1 hour medevac to a hospital is low risk, 1-1.5 hours + is medium, 1.5 + is high.

As a decision maker during my previous career in the military, I was introduced to a standard risk analysis/risk decision process in the mid 80’s. This example card below was used just for training events, which is why you do not see categories for Enemy Strength, Enemy Cohesion, etc. Imagine that being added to the card as projected incident behavior.

This card is a distillation of the probability/severity matrix, listing the routine variables encountered in training soldiers. This is a “Big Army” tool, so there’s no underwater/night diving type categories, just a plain vanilla tool to help quantify the discussion and get leaders a common operating picture around risk. In Special Forces, we had more sophisticated versions, taking into account such arcane factors as infrared crossover times, moon phase and illumination, solar flare activity, etc. Think 1000-hour fuel moistures and Haines Index.

Once you include the variables of fire weather and fire behavior, and adapt to other common wildland variables you could now have a probability/severity matrix in the AA briefings or tactics meetings and come up with some actual number values to plug into a modified 215A.

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Example Card of Risk Analysis/Risk Decision

This would provide a more quantifiable approach. Inevitably, there will always be situations that despite well-planned mitigations, we’ll still have a residual risk score of high risk. Let’s say a 25 using the above laminated card. This is when we must circle back to the beginning — the values at risk, the “purpose” in leader’s intent. By looking at the acceptable risk table example, you’d see that High risk is just not an acceptable risk to save three chicken coops and a hillside of PJ.

Now what? If we cannot lower the risk through alternate tactics, then we’ll need to back up to the previous C&GS meeting-Strategy. We’ll have to find an alternate strategy to lower that risk and still accomplish the objective. If we can’t create an alternate strategy to lower the residual risk to acceptable, then we need to back up even more and re-look the objective the strategy was meant to accomplish. This process would force decision makers to become way more strategic on suppression actions –- continue the evolution in engagement thinking that moves towards the best ridge versus the next ridge.

The problem with this kind of thoroughness is that it requires time. If an artificial deadline such as IAP production due to copier availability or other factor is driving the quality of our risk analysis, then the tail is wagging the dog.

The question remains, what if we have to accept high risk? Let’s use our earlier example OK, we’ve planned all these mitigations and we still have a residual risk score of 25, high riskbut this time, let’s use a different value at risk and the same acceptable risk guidelines. “The VaR is one of the primary transmission lines of electricity to Phoenix and it’s 114 degrees. High risk is acceptable because if that power shuts off some at-risk people are going to die.” That’s probably a very appropriate risk level.

Finally, in order to have a well-founded risk decision, it is essential to share the risk. Shared risk has been a recent buzzword in wildland fire, but it’s important to truly understand what it means. Shared risk means national leaders create the acceptable risk guidelines based on values at risk, such as the example table. This means they’ve shared the accountability and the risk of putting firefighters to protect the powerline in the example above. It means AA’s and IC’s make the prioritization of the values at risk part of the delegation and dialogue. This increases the quality of fire management interactions with line officers in pre-planning and once fires start.

The net result of this is that everyone involved—national leaders, agency administrators, incident commanders—share in the accountability. It means IMT’s conduct risk assessments with proper tools for the gravity of the job, use more objective criteria, and create leader’s intent with task, purpose and end state. By tying purpose back to a specific VaR, and making the decision on whether the risk is acceptable, now they share in the accountability.

But shared risk means it is also shared down to the operator level. This is way more than having a simple turndown protocol. In the current system, the turndown consideration is completely subjective. “I just don’t feel comfortable.” When operators receive a Division Assignment Sheet (ICS 204), they have no way of knowing what risk level they’ve been asked to accept, so they have no start point to go through the risk management process at their tactical level. A quality 204 would include this: Special Instructions: Risk Level – HIGH – due to increased density of snags in Division A.

If we routinely included the task, purpose, end state on a 204, then each DIVS and crew leader would also understand the VaR they’re being asked to protect. If we included Low, Medium, High, etc. on the 204 then they would know the risk level the IMT decided was acceptable for that VaR. If the acceptable risk guideline table was in the IAP, then they would have all the required ingredients for their own “Does the outcome justify the risk?” assessment at their level and — most importantly — to judge acceptable risks as conditions change throughout the shift. Even in a string of mop up shifts, low risk yesterday could be high risk today because of a wind event overnight. Now crew leaders and sub leaders too, are accountable for risk decisions. That’s what shared risk truly looks like.

Current tools and practices are lagging farther and farther behind the increasing complexity of the wildland fire environment. The growing gap means that more and more, we are relying on luck for success. The worldwide gaming industry’s $90 billion dollars of annual revenue is made possible by one universal truth: “Luck Runs Out.”

The evolution and use of a few simple tools could have a significant impact on the worthy goal of “significantly increasing the odds of everyone going home” at the end of the next fire season. Let’s move wildland fire’s risk management process from the 70’s and 90’s to the 21st Century.

Who is on Your Crew?

By Lyndsay Alarcon, Helitack Superintendent1541799144541

Crew Resource Management (CRM) is the application of team management concepts in the wildland fire environment.  CRM originated as Cockpit Resource Management and was developed by NASA in 1979.  At that time, the majority of aviation accidents were caused by human error related to failures in communication, leadership and decision making in the cockpit.  The term has since been expanded from cockpit to crew with the fundamental goal being better decision making through how we interact with each other.  Who does “each other” include?

Although team management is not a new concept, CRM places a different perspective on the meaning of team.  It redefines team work to include all personnel needed to achieve the success of a mission.  Let’s use an example of a medivac to extract an injured firefighter.  The team would be comprised of the dispatcher flight following with the aircraft and making notifications, the medical unit leader organizing hospital care, the municipal firefighter serving as a line medic, the IHC crew constructing the helispot, the helitack crew and pilot, the mechanic who maintains the helicopter, etc.  Any failure in communication, leadership or decision making from any player directly impacts the success of the mission.

Our perception is embedded in the slogan, “Taking Care of Our Own”.  We tend to take this direction and think linear.  “My team” is my crew and as long as my crew is good, then I am good.  My actions only change when there is a threat to my crew.  If each person applied this thought, “taking care of their own”, how do we ensure overlap on an incident?

The reality is that sometime there isn’t any.  The Dutch Creek incident is an example of how the interaction of people can effect leadership, communication and decision making.  The cultural gaps still standing between CalFire and USFS even in the face of fatalities.  It is why so many individuals can see the rotating plume on the Indians fire and not say anything.  It is not that they don’t talk, it is that they communicate the message to who matters to them.  If we acted like the success of the mission depended on our partnerships, then we would value each other differently.

The 2018 season was costly.  We lost many, including hired contractors, agency partners and volunteers.  I can’t help but to wonder how they are supported beyond the mandatory briefings, the sack lunch and pay check.  Who brings them into the team?  How does that affect the moments when we need each other the most?  Starting day one, were they cared for as if they were truly one of our own?

Consider enlarging who you think of as “your crew”. It could make all the difference.

 

Most of Firefighting Sucks

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You should go read this piece by Amanda Monthei. She knows what’s up.
This is an excerpt:

“This night was pretty fun until it wasn’t, and then it straight up sucked. Not only did our line not hold—requiring three more days of work to contain it on the other side of the road—but many of us agreed that it was probably the worst smoke exposure of the summer. Smoke exposure is the worst part of our job, and its effects don’t go away once you reach fresh air. Your eyes will dry and the snot will stop, but you’ll still wake up feeling like you got black-out drunk and smoked a pack of Marlboros the night before. Your voice will be raspy. Your lungs won’t feel quite right. Your throat will be sore. You’ll have a headache.

That all said, this was probably one of the most memorable nights of the summer—probably because it sucked so bad. Most of firefighting sucks to some degree, but breathing smoke and nights that never seem to end rank right up there with the worst of it. The real question is why the hell we continue to do it.”


Go read the full article:

https://www.amandamonthei.com/blog/2018/10/27/in-defense-of-things-that-suck

Honor The Fallen

By Travis Dotson

How exactly do we Honor the Fallen?

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It’s a tough question because it has a thousand right answers. One of the most important ways to honor is to learn. We are always in danger of squandering the bitter opportunity that tragedy affords us.

This video is a glimpse of what so many of us struggled with in the aftermath of the Yarnell Hill Fire. This is just a few fire folks walking the ground in January 2014 and grappling with how to advance our culture in the aftermath of devastation.

Take a look.

Making sense of bad outcomes is difficult, often impossible. But nobody wants the pain to be without benefit. Suffering without growth is tragic.

Let’s choose growth. One way to grow is to challenge long held beliefs. The window for genuine inquiry opens wide after disorienting circumstances – when we are shaken we struggle to re-balance. For many the re-balance means doubling down on long held beliefs, for others it requires a heart wrenching letting go of previous convictions.

What are some of your long held beliefs?

Are you willing to question them?

Are you willing to consider a new perspective?

And after all that, are you willing to actually alter your actions?

Growth is difficult.

Honor the Fallen

 

 

Old Boss Says…

The following letter is directly from the Redondo Escaped Prescribed Fire FLA

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TO: Current and Future Burn Bosses

FROM: An Old Type 1 Burn Boss

As an Old Type 1 Burn Boss, I’ve had the opportunity to work with a ton of great people and do what I believe is a lot of awesome work within our fire adapted ecosystems. This was my first time serving on Facilitated Learning Analysis (FLA) team. If you have the opportunity, I encourage you to participate on an FLA team. Please don’t wait as long as I did to get involved. Never stop learning, never stop communicating, and always strive to BE A STUDENT OF FIRE.

As a Prescribed Fire Burn Boss you operate in a very complex and ever changing environment. You spend months preparing for an event, and all along you need to be gathering situational awareness:

• Who will be on that hill at a specific time?

• Did I order enough blue houses?

• Will the food be on time?

• What piece of equipment will break down?

Oh, and don’t forget your day-to-day job requires a facility check next week and a hundred other things.

As a current burn boss, spend as much time as possible with future burn bosses. Teach new burn bosses to document everything, even if they think it is trivial. Why? Because to truly move forward with a learning culture, you have to be able to tell your story, and trust me, notes are golden.

As an Old Type 1, I want to share my experiences with you. Some learning was easy, some came the hard way. I’m sharing with you today with the hopes that you may learn from my scars.

• COMMUNICATION – COMMUNICATION – COMMUNICATION. Up, down, sideways. Never stop.

• Utilize the District as an ID Team to ensure your complexity analysis and burn plan is robust.

• Build an organization around yourself for support.

  •  This could be as simple as utilizing the type 3 militia.
  • Find the person that can locate anything, anywhere, and get them to assist with logistics.
  • Make sure you have plenty of drivers.

• Use an Incident Action Plan (IAP) and take the time to update all the blocks. The IAP will become your most critical piece of documentation.

• Invite overhead in at least two shifts prior to ignition. This will ensure everyone is familiar with the plan you’ve been working on for the past six months.

  •  Challenge these overhead resources to read the plan, to find what is missing, to poke holes in it – so that your plan becomes their plan, and is better for it.
  • Make time for a small command meeting before your first briefing. This will allow you to gauge the employees you have on hand and provide a chance to identify any resources/needs that are lacking.
  • CHECK RED CARDS.

• Partner with your dispatcher – they are extremely important to your success. Use ROSS to track assignment and qualifications of your people.

• Be in constant communication with your Agency Administrator (AA).

  • During the writing of the burn plan and complexity analysis, have meaningful dialogue with your AA. They are sharing the risk with you. If you can’t have a meaningful conversation or you don’t feel comfortable they are sharing the risk, STOP–THINK-TALK-THEN SIGN. Remember this is not about just checking a box.
  • If possible, have the AA on site for the entire event, or at a minimum during the critical shifts.
  • The AA is your partner during the burn; if you are not getting what you need, ASK – make some noise – get what you need.

• During the technical review process, ask for honest feedback and don’t take comments personally. Honest feedback helps you learn and makes for a better plan.

• Smoke is so very important, don’t just look at what the smoke is doing around the fire – look to where it will be that afternoon and where it will settle during the night.

  • Look at the area you could affect and double it.
  • Get the word out early and often.
  • Make sure you know who your smoke sensitive individuals are.

• Create a partnership with your district and/or forest PIO. Use the winter to provide information to the public and tell the good story about prescribed fire. Perhaps go with your AA and do some media interviews.

• Always look at ordering a FEMO for your prescribed fire events. This person is your weather and fire behavior documentation leader.

• Look at bolstering your fuels program. A strong fuels specialist will take your planning to a new level.

• REMEMBER:

  • BEING FLEXIBLE IS WAY TOO RIGID
  • YOU CAN ONLY BURN AS FAST AS YOU CAN HOLD
  • EVERYONE IS WILLING TO HELP, YOU JUST NEED TO ASK!

Thank you for all your hard work and never forget it is an honor to be a Burn Boss!

– Old Type 1 Burn Boss


Read the full report: Redondo Escaped Prescribed Fire FLA

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Chances Are…

Burning anytime soon?

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As you get the fuel mixed and the torches set…

Check this out:

 

Chances are…

You will get the job done.

You will be “successful”.

You will feel pressure to burn.

Unforeseen delays will put you behind the power curve.

You will not follow every aspect of your plan.

Problems will come from areas you least expect.

An emergency will highlight previously unknown communication issues.

Small problems will snowball.

The predicted weather will change and become unfavorable.

You will underestimate fire behavior.

You will not have to use your contingency plan…

If you do you will discover it’s inadequate.

If you read an escape RX review you’ll say “what were they thinking?”

As you burn this season, chances are you will be “successful.”

Are you good or lucky?


 

What do you think?

Are Your “Slides” Blinding You?

By Persephone Whelan


So there I was, snuggled on the couch in the early morning hours with my 3-year-old, sipping coffee, idly flipping through Facebook when a Hotchkiss Fire District video of the Horse Park Fire came under my thumb. I thought, “Wow. That’s some interesting fire behavior. Wonder what the story is there.” Then I was interrupted with a request for more Paw Patrol videos or something.

Later on that day, a buddy called me up. “Did you see that video from the Horse Park Fire?! What were they thinking?”

STOP RIGHT THERE!

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Do I have your attention? Maybe half of it while you sip coffee, eat a sandwich, ride down the road? I’ll take what I can get. I want to stir the pot and see what comes up.

Have you ever been watching a video or reading about a near miss or something particularly hairy on a fire and heard someone say: “If they just stuck to the basics they would have been fine.” Or “What part of ‘base all actions on current and expected fire behavior’ did they not understand?” Or “How could they not see that coming?” Have you ever had these thoughts or conversations?

Let’s talk about THIS.

But before I launch into a series of questions and ideas to “stir the pot” I need you to take a moment and suspend your personal beliefs. Ready? Here we go.

Setting Us Up for Failure

Why do we keep getting surprised? What do we expect arriving on scene of an incident?

I would like to propose that this is where we have culturally strapped on the blinders. Your “slides,” your past experiences on fires, may be blinding you to what is right in front of you—and the possible future.

Perhaps we need to let go of the Recognition Primed Decision Making model. YIKES! What did she just say? I’m proposing this model, this mode of thinking, is setting us up for failure. Time to leave the 80s in the 80s and challenge our ways of thinking today.

No one starts their shift with the intention of only having half their situational awareness. Everyone starts their day, their strategy, or their tactics thinking that they have complete SA. They make decisions based upon that information they feel they are getting or matching-up to previous situations they have encountered. Sure, this practice might initially seem to work—right up until that moment everything goes to hell and they are running, thinking: “Wow! How did I lose my SA?”

Do you think the individuals in the Horse Park Fire video or FLA started their day thinking: “Hey I want to see how close I can get to being burned-over without actually getting hurt.”  Or: “I’m going to totally ignore the Fire Orders and Watch Out Situations when I go scout this fire because they don’t really work for me.”

You do not lose your SA. I once heard someone say, losing your SA is only possible if you are unconscious. You are only a human capable of processing X amount of data. It’s HOW you process that data that matters the most.

Mindfulness

Allow me to drop a hefty word on you: Mindfulness. If you are starting to picture hippy music, incense, meditation, etc., please pause. I am talking about mindfulness in a science/nerd type of way, not in a “gentle or nurturing” Buddhist approach. I’m talking about HRO mindfulness. Navy SEALs have mindfulness training. You picking up what I’m throwing down?

HandFire2

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Why does all this matter?

Judgements happen when you compare what you are seeing to a model, experience or “slide” in your mind. Once you make a judgement, your perspective is tailored to that moment. How closely does this scenario match others I’ve encountered? What tactics work best?

This leads you down a path where you may not be “seeing” what is going on around you because you already have a perspective selected which tailors the inputs to your mind. Everything else just washes away. You have now lost your SA.

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How is This Moment Different?

Here is where I ask you to make one subtle, yet very important shift.

Instead of asking yourself: “How does this scenario, this IA, this Division, etc. match others I have encountered before?” Ask yourself: “How is this moment different?” Instead of asking: “What worked before?” Ask: “What options do I have?”

Be creative. Be curious. Tune into your senses. Use the environment and the tools you have to engage—constantly reassessing what is different. And what needs tweaking.

On the other hand, asking yourself “What is working?” is confirmation bias and a dark path to travel. That kind of thinking reaffirms what you already “think you know” and leads to mindlessness and not mindfulness.

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Stop Trying to Make a Square Peg Fit a Round Hole

I do agree with those people who comment “Why were they surprised?” But I have a different perspective. Is it not common to joke “What is normal?” I haven’t heard many firefighters arguing that conditions or fires are the same as they were 20 years ago. If our fires aren’t normal, why are we using “normal” tactics?

“We’ve always done X” is a weak argument. I think this is how people get surprised. Stop trying to make a square peg fit a round hole. Stop forcing tactics that used to work on our current situations. We are a professional, adaptable group that performs at a high level in chaos.

Seek opportunities to allow your brains to operate at that high level without putting blinders on the inputs. Talk among yourselves, ask questions and listen to each other. Most of all <gasp> be safe out there!

Want to Know More?

Want to try to understand where these crazy ideas came from? Check out these sources:

  • Conklin, Todd. “What is all this talk about Mindfulness – Ellen Langer is someone you should know.” Pre Accident Investigation Podcast 151. December 9, 2017. https://www.podbean.com/media/share/pb-52idj-7d8e50
  • TedX Talks – “How to tame your wandering mind” by Amishi jha.
  • Fraher, Amy, Branicki, Layla and Grint, Keith. (2016) Mindfulness in action: discovering how Navy SEALs build capacity for mindfulness in high-reliability organizations. Academy of Management Discoveries.
  • Dotson, Travis. Ground Truths “Experience Builds Bias.” Two More Chains. Summer 2017. Vol. 7 Issue 2. Wildland Fire Lessons Learned Center.

 

When You Have to Run

By Travis Dotson

You should read this one. It’s straight up scary.

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We’ve talked about this before, how normal ops can get sketchy in a second.

Here it is. Real-deal run for your life type stuff.

First fire of the season. First shift.

Just scouting a road. Just serving as Lookout.

Normal ops.

Watch this:

Read the report to get the full details.

Read the section on lessons – discuss the questions posed.


Get full report here:

https://www.wildfirelessons.net/viewdocument/horse-park-fire-entrapment-2018

Pinched Bar, Broken Fibula

This is an excerpt from the “Coconino Felling Accident RLS


The assignment for the day was to prep dozer line, cut a canopy break along a handline, and continue with prepping a road that the handline tied into.

The saw prep primarily consisted of limbing, bucking, removal of small diameter trees, and felling any snags that would impact the control lines or affect the safety of personnel.

The Sawyer’s upper body was brushed by the bole of the tree as it came down from swinging in the air. The tree then landed on the ground and pinned the Sawyer’s lower left leg as the individual attempted to use his escape route.

Cutting Procedure

The tree that caused the injury was a ponderosa pine snag approximately 50 feet in height and 26 inches DBH. After completing a “size-up,” under the direct supervision of a qualified C Faller, the Sawyer began his face cut on the right side of the tree in relation to the direction of the fall. The individual then moved to the left side of the tree to finish the face cut as the diameter of the tree was longer than the chainsaw bar and required a “double cut”. At this point, the Sawyer was on the uphill side of the tree when the back cut was started. This required the individual to get on one knee to put the back cut at the appropriate height in relation to the face cut.

The Sawyer began his back cut, but noticed it was sloped and began another back cut under the original attempt. While working the back cut, the Sawyer also attempted to bore the heart wood and unintentionally cut through all the intended holding wood.

While the saw was still in the tree and the Sawyer was still working on the back cut, the nearby C Faller yelled “It’s Going!” and the Sawyer began to stand and attempted to pull the saw from the stump and access the escape route. However, the tree was already hitting the ground as the Sawyer attempted to flee the stump.

Tree Lands on Sawyer’s LegScreen Shot 2018-06-28 at 1.56.51 PM

As the tree’s top brushed another tree, it made the bole rise into the air and roll off the stump onto the Sawyer’s leg before he was able to vacate the cutting area.

The Sawyer was on the uphill side of the tree when the back cut was started. This required the individual to get on one knee to put the back cut at the appropriate height in relation to the face cut. The C Faller immediately ran to the pinned Sawyer, grabbed the chainsaw, and bucked out the section that was trapping the Sawyer.

Two EMTs were shortly on scene to assess the patient. They determined that the patient was stable. The Supervisor made the assessment that self-transport to a medical facility was the quickest and most appropriate action.

A cell phone call was made to the Duty Officer to keep them apprised of the situation. The Duty Officer made other notifications at the Forest level.

The Sawyer’s injuries were all sustained to the lower left leg. Those injuries included a fibula break, a puncture wound, and a torn muscle.


Rather than a bunch of hindsight fueled “should haves

Share your personal lessons in the comments


Read the RLS document here:

https://www.wildfirelessons.net/viewdocument/coconino-felling-accident-2018

“Just Let Me Finish”

By Travis Dotson

This is about a firefighter physical training fatality. Let me tell you why this scares the crap out of me. This PT description sounds very familiar.  We get up and go for a group run fairly regularly. You might point out that this instance is different because it’s a structural department. That is exactly why it scares me even more. These folks are medically trained to a much higher degree than any wildland crew out there.

And he died.

Read this and reflect on your own PT program.

PT_1

Typical PT Run

Are you ready?


The following is an excerpt from the NIOSH report “Fatal Exertional Heat Stroke During Physical Fitness Training“.


On April 20, 2009, a 26-year-old male career Firefighter Trainee began a 2-month firefighter certification program. On April 29, 2009, the Trainee participated in a 4.4-mile jog as part of the physical fitness portion of the program.

The temperature 73 degrees °F with 87% relative humidity.

The 36 students began the day (Day 6 of the program) with physical fitness training consisting of stretching and jogging two laps around the track (1/4 mile per lap) as a warm-up exercise. At about 0610 hours, the group began a 4.4-mile run/jog in formation on neighboring streets. The group was led by a FD vehicle and followed by a FD squad. Four instructors participated in the run, which lasted approximately 1 hour, 10 minutes.

A Captain led the group, calling cadence while another Captain ran in the back of the class. Nearing the end of the run, students were instructed to break formation and sprint to the finish line, approximately 1/8 mile. Three students were lagging behind, including the Trainee. Two nearby classmates went to encourage the Trainee, who was stumbling and seemed disoriented. When asked if he was okay, he said “just let me finish.” The Trainee stopped running and began walking in an unsteady gait. A class officer, a FD Captain, ran over and helped the Trainee lie down with assistance from the other students. Water and a medical bag (containing oxygen, blood pressure cuff, and a glucometer) were retrieved. According to the students, the Trainee was pale, sweaty, shivering, incoherent, and unable to communicate.

911 was called (0727 hours), and an ambulance was dispatched (0728 hours). A paramedic on the scene found the Trainee to be unresponsive, with a rapid pulse of 170 beats per minute, a rapid breathing rate of 24 breaths per minute, and low blood pressure of 60 mmHg by palpation. Ice packs were placed on the Trainee’s skin, oxygen was administered, and an intravenous (IV) line was placed. His blood glucose level was normal (95 milligrams per deciliter [mg/dL]).

The ambulance responded at 0730 hours and arrived on scene at 0739 hours. Paramedics found the Trainee unresponsive, with essentially no change in his vital signs from 0729 hours. A 12-lead electrocardiogram (EKG) revealed sinus tachycardia (rapid heart rate) with inverted T-waves (a nonspecific finding). A second IV line was placed, and the Trainee was given fluids to treat dehydration and heat exhaustion. His axillary (under the arm) temperature was 103.4°F, and four new ice packs were placed on his skin. The ambulance departed the scene at 0752 hours en route to the local hospital’s ED. En route, the Trainee’s blood pressure increased to 80 mmHg systolic (by palpation), but his fast pulse and respiratory rate remained unchanged. He remained unconscious throughout the remainder of the 19-minute transport.

The ambulance arrived at the hospital’s ED at 0811 hours. The Trainee’s vital signs revealed a blood pressure of 106/52 mmHg, a heart rate of 150 beats per minute (tachycardia), and a respiratory rate of 24 breaths per minute. He was sweating heavily and had a core body (rectal) temperature of 105.3°F. The initial diagnoses were hyperthermia, severe dehydration, and heatstroke, followed by heatstroke complications including the following:

  • Rhabdomyolysis (breakdown of muscle fibers resulting in the release of myoglobin into the bloodstream)
  • Acute renal failure due to rhabdomyolysis
  • Disseminated intravascular coagulation (DIC) (a blood clotting disorder)
  • Electrolyte imbalances (low potassium and calcium)

He was treated in the ED with ice packs, cooling fans, cool IV fluids, and cold towels. Despite this treatment, his rectal temperature was 104.7°F 3 hours after his arrival in the ED, and 101°F 12 hours after his arrival in the ED.

The Trainee was transferred to the intensive care unit where IV fluids and cooling blanket therapy continued. Over the next 4 days his mental status improved; however, many of his organ systems (i.e., muscles, liver, kidneys, and blood coagulation) began to fail from heatstroke complications. On May 3 his neurological status declined, and he began to have respiratory failure that required intubation. A computed tomography (CT) scan of his brain revealed marked cerebral edema with herniation. After consulting with the family, the physician removed the Trainee from life support on May 4; he died 41 minutes later.


Read the full report here:

Fatal Exertional Heat Stroke During Physical Fitness Training