The Human Factors Analysis and Classification System—HFACS
1. Unsafe Acts
for Unsafe Acts
3. Unsafe Supervision
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
Forward by James Reason
2. Definitions and Principles of a Just Culture
3. Creating a Just Culture
4. Case Studies
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
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."
RAINBOW SPRINGS FIRE
INCIDENT COMMANDER NARRATION
Given February 1997 for use in the Fatality Fire Case Study Training Course
In August of 1979, I began my assignment as Timber Management Assistant
(TMA) on the Mena Ranger District, Ouachita National Forest at Mena, Arkansas.
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.
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
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
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
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
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
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
reading Rainbow Springs Fire, April 25 >>>