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

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1 Preventing The Next Tragedy Fire A Leadership Challenge And Responsibility

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

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Preventing The Next Tragedy Fire

A Leadership Challenge And Responsibility

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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?

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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

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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

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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.

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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 ….

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Current System Relies On Assumptions

Assume expectations are followed

Assume expectations are followed

Assume expectations are followed

Assume expectations are followed

NationalExpectations

RegionalExpectations

ForestExpectations

DistrictExpectations

IncidentExpectations

Current System

BadOutcomes

BadOutcomes

BadOutcomes

BadOutcomes

Accountability for: Feedback Control System:

BadOutcomes Individual

Expectations

Assume expectations are followed

Assume expectations are followed

Assume expectations are followed

Assume expectations are followed

Assume expectations are followed

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Desired System Relies On Knowing Expectations Are Met

Monitor to ensure expectations are met

NationalExpectations

RegionalExpectations

ForestExpectations

DistrictExpectations

IncidentExpectations

Desired System

Monitor to ensure expectations are met

Monitor to ensure expectations are met

Monitor to ensure expectations are met

MeetingExpectations

MeetingExpectations

MeetingExpectations

MeetingExpectations

Accountability for: Feedback Control System:

MeetingExpectations Individual

Expectations

Monitor to ensure expectations are met

Monitor to ensure expectations are met

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Two Safety CulturesAn Assuming Culture A Learning Culture

Communicate expectations Communicate, 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 unexpected Ready for the unexpected

Accidents will happen Learn how to prevent

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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

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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

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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

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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

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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

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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

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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

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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.

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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

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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

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Strategy For Creating The Desirable Future:

Transform the organization by developing and implementing quality

assurance systems.

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What is success?

Individual Performance

Effective Operations

Effective OrganizationSuccess = ++

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!

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Quality Assurance Systems

Individual Performance

Effective Operations

Effective OrganizationSuccess = ++

Quality Assurance Systems In A Learning Culture Context

Relentless pursuit of quality will lead Fire and Aviation Management to become a learning

organization!

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Goal Evaluate & Learn

ImproveOrganization

Evaluate & Learn Improve

Policies, Practices, & Procedures

Goal

Improve Operations

GoalEvaluate & Learn

Individuals Goal

Evaluate & LearnImprove

Fire & Aviation Management Learning Organization:All parts of the system develop and learn through continuous

improvement feedback loops.

FeedbackLoop

FeedbackLoop

FeedbackLoop

FeedbackLoop

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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

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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 LoopOrganizing for Effectiveness

Line Officer Incident Performance Review

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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

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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

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Individual Performance Feedback Control Loop

Effective Individual Training

Incident Experience

Simulation Experience

Performance Improvement Plan

Performance Evaluation

Audit & Certification & De-Certification

Feedback Control Loop

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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

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Safe OperationsFeedback 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

Monitor Operations

Evaluation

Feedback Control Loop

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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

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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

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Decision Support ConceptWeather Factors

Current & Predicted

Fire Behavior Factors – Current &

Predicted

Organizational Factors

Risk Assessment

Operations Normal

Operations Yellow

Operations Red

Monitoring & Intervention Protocol 1

Monitoring & Intervention Protocol 2

Monitoring & Intervention Protocol 3

Decision Support System

Predisposing Thresholds By Fire

Regime & Fuel Model

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The Decision Path Is Critical To Safety AND Cost Containment!

Incident Decision Path

Detection

Initial Attack

DispatchSize Up

Fire Operations Decision Support System

Extended Initial Attack

Type II Incident Type I Incident

Controlled

Transition Transition Transition 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

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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

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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

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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!

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To Prevent Tragedy

We must replace assumptions with monitoring and improvement to stop that last 2% of critical errors

from occurring.

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Hazard Defense System

PotentialLosses

LEADERSHIP

POL/PRA/PRO

TRAINING

MONITORING

Hazards

IPROVEMENT

A risk management system that continually improves in performance is an impenetrable containment for hazards.

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Discussion

No leadership action or inaction is worth a life lost.

What is leadership going to do to prevent the next tragedy fire?