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Swiss Cheese Model

swiss cheese slice

The Human Factors Analysis and Classification System—HFACS

Cover and Documentation
1. Unsafe Acts
2. Preconditions for Unsafe Acts
3. Unsafe Supervision
4. Organizational Influences

HFACS and Wildland Fatality Investigations

Hugh Carson wrote this article a few days after the Cramer Fire

Bill Gabbert wrote this article following the release of the Yarnell Hill Fire ADOSH report

A Roadmap to a Just Culture: Enhancing the Safety Environment

Cover and Contents
Forward by James Reason
Executive Summary
1. Introduction
2. Definitions and Principles of a Just Culture
3. Creating a Just Culture
4. Case Studies
5. References
Appendix A. Reporting Systems
Appendix B. Constraints to a Just Reporting Culture
Appendix C. Different Perspectives
Appendix D. Glossary of Acronyms
Appendix E. Report Feedback Form

Rainbow Springs Fire, 1984 — Incident Commander Narration

Years Prior
April 25th
Fire Narrative
Lessons Learned

U.S. Forest Service Fire Suppression: Foundational Doctrine

Tools to Identify Lessons Learned

An FAA website presents 3 tools to identify lessons learned from accidents. The site also includes an animated illustration of a slightly different 'Swiss-cheese' model called "defenses-in-depth."


Given February 1997 for use in the Fatality Fire Case Study Training Course

April 25th

As usual, we came to work on the Morning of April 25, 1984 with fire being the last thing on our minds. It had been decided about a week earlier that our spring fire season was over and the fire staff officer had released the air tanker that was under contract for the forest. About 4 days earlier we had received over an inch of rainfall that helped disguise the extreme fire weather that would be experienced later that day.

While we were not thinking fire, none of us expected April 25th to be just another day. We had very serious personnel problems. One of our primary technicians was under investigation for serious ethic and conduct violations. The overall morale was extremely low. We had planned a district meeting during that afternoon to discuss our problems and identify ways to come together as a district.

Sometime during that morning the District Ranger and I traveled to the field to look at some timber marking in progress. At about 1100 hours I noticed the wind was very strong from the southeast. I remember thinking for a moment that the fire danger must still be very high because in addition to the wind, there was not as much green vegetation as one would expect that late in the spring season. We returned to the district office just before noon to make final preparations for our district meeting that was scheduled for the afternoon. At about 1330 hours the, aerial observer reported a fire in the Rainbow Springs area and described the fire as spreading very rapidly. Once he gave the legal description, I realized the fire must be burning in an active timber sale with heavy pine slash and probably on the steep south facing slope of Dallas Mountain.

As unprepared as we were, we wasted little time departing to the fire. The ORA, who had been on the district less than one year asked me to accompany him to the fire. As soon as we cleared the office parking lot we could see a very large column of black smoke that appeared to be in the vicinity of Rainbow Springs.

Travel time from the office to the fire was about 15 minutes. What I remember most about that trip was the ORA’s suggestion that no matter what happens, things cannot get any worse. My reply was “Oh hell yes they can too”. I was thinking about our young inexperienced people and was concerned about their mental state due to the aforesaid problems. I was also thinking about our new tractor operator that to my knowledge would be operating his first fire. I did not know for sure who would be IC but felt I would be asked to assume that responsibility once we reached the fire. Therefore, being familiar with the terrain and fuel conditions, I was already thinking about a plan of action.

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