Colorado Firecamp - wildfire training wildland firefighter training Wildfire Blog Engine Boss Apprenticeship Location and Facility About Colorado Firecamp Frequently Asked Questions

Colorado Firecamp - wildland firefighter training
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

Years Prior

In August of 1979, I began my assignment as Timber Management Assistant (TMA) on the Mena Ranger District, Ouachita National Forest at Mena, Arkansas. My red card classification was Fire Boss III mainly due to my heavy involvement in fire suppression during the past 5 years which I had spent as Timber Management Assistant on the Andrew Pickens District in Walhalla, South Carolina. The timber program on the Mena District was much larger and more challenging than what I had dealt with on the Andrew Pickens District. I was having to spend about all of my time on the timber program and had very little involvement with fire suppression. The main reason for my lack of involvement in fire however was the Mena District organization had placed fire management under the Other Resource Assistant.

Although the Mena District experienced a few small fires during the fall and winter of 1979, I was not asked to participate in any of them. I was not asked to participate in fire suppression until April 4, 1980. On that day of extreme fire danger caused by high wind and low relative humidity, the Tower Mountain Fire was reported on the Mena district. I was dispatched to the fire not knowing what my job would be and was somewhat surprised when the ORA requested that I take charge of the fire.

Since I had not worked a wildfire with the district crew, I had no idea how they would perform. Although the fire danger was approaching extreme, I really could not anticipate a problem. The fire was less than 1 acre in size and our tractor and about 12 firefighters were already on the scene. My optimism soon faded however when I noticed the tractor operator was extremely nervous and showed signs of inexperience. The hand crews were having trouble locating their personal protective equipment and showed absolutely no sense of urgency. The unnecessary delay resulted in the fire moving from its origin in a relatively flat flood plain to the base of a south facing slope. A few minutes later a strong gust of wind sent the fire running up slope and only with the aid of an improved pasture in front and on the right flank of the fire were we able to contain it at about 100 acres. A Forest Service engine crew and a local fire department had to work at a frantic pace to save a very expensive dwelling from going up in smoke. It was a totally different show than what I had become accustomed to seeing during my time on the previous district. A fire of that size and intensity at initial attack would have been quickly suppressed and forgotten.

The only comfort I could find with that unpleasant experience was my recollection of how a young and inexperienced group of technicians on my previous district had been molded into a very effective firefighting organization in a relatively short period of time. I felt that with the quality of people we had on the Mena District, we too, could make substantial improvements if we were willing to give a higher priority to fire management.

The following day I requested a meeting with the District Ranger and ORA in hopes we could get started on fire training for our people and develop a district fire organization for future fires such as the one we had just experienced. I expressed to them my concern for what I felt was a very dismal performance on the Tower Mountain Fire and emphasized that it was a matter of luck that no one was seriously injured or killed.

It was obvious during our short meeting that we were on a different wavelength and did not share the same concerns. For example, when I requested that the tractor operator be replaced, I recall one of them saying that he realized the operator was nervous and very slow but he takes very good care of the equipment. I did not feel then, nor do I feel now, that they had any less concern for employee safety than I did. Apparently, they had very limited firefighting experience and could net comprehend the safety risk associate with using people without proper training and experience in initial attack operations. Although the Mena District was the site of the largest fire (Eagleton Fire — 15,000 acres) that had occurred on National Forest Land in Region 8, there had not been a fire related fatality in the 76 year history of the Ouachita National Forest. Perhaps that historical fact led some to believe that killer fires were not possible in that part of the country.

The summer following the Tower Mountain Fire (1980) produced the longest period of extreme fire danger that is on record for the Ouachita National Forest. Fortunately, we were able to get a lot of help in both firefighters and air tankers from the western regions because they experienced unusually low fire activity during that same period. While Class E days were the norm from early July until mid September, the Mena District district had only two small fires until a very windy day in early September. On that day the Acorn Fire escaped from a railroad right-of-way and threatened numerous homes and a local school. We were very fortunate to have a helicopter/bucket and 8 air tankers with very short turn around times. As IC, I could see no improvement in our fire organization from the Tower Mountain Fire a few months earlier. Several of our people were already on the fire when I arrived but for most of the afternoon and certainly during the most critical period, I only had radio contact with the District Ranger and Timber Sales Administrator. I found out later that a key member of the district staff had taken most of our people to rake a line around a dwelling near the origin of the fire and in the process turned his radio off. The fire was contained without a personal injury. A couple of poultry houses were destroyed but that happened before the Forest Service took charge of the fire. I expressed concern to the District Ranger but a letter of commendation from the local director of civil defense giving us much praise that no dwellings were destroyed seemed to carry more weight. In reality, this operation was an air show and the commendation letter would have been more appropriate for the helicopter and air tanker pilots.

In late September of 1980 we received a general rainfall that ended the famous Summer of 80 Drought. We had endured a long, dry and very hot summer. Most of us had not had a day off in months. Once the drought was broken, the last thing we wanted to think about was fire. For the next 3 1/2 years we pretty much got our wish — thanks to the unusually low fire danger during that period.

We did have a modest prescribed burning program during that 3 1/2 year period. Perhaps that program could have been used to some extent to train our young and inexperienced technicians. As I recall, the ORA and Wildlife Biologist prepared the burning plans and gave them to the Timber Sales Administrator for implementation. The Timber Sales Administrator had a lot of pride in his burning skills but did not share those skills with the younger employees. They were relegated to carrying a torch under his very close supervision or patrolling the control line for spot-overs. Management seemed content to let that happen. To make matters worse, we lost 3 of our most experienced technicians to retirement during that period and replaced them with young people that had very little fire training and fireline experience. The Timber Sales Administrator retired in January of 1984, about two months before the day of the Rainbow Springs Fire.

<<< continue reading Rainbow Springs Fire, April 25 >>>


©2005-2006 Colorado Firecamp, Inc. home scheduleblogENGBfacilityabout usFAQ's