Creating a Passion
Management Oversight & Inspection
Jim Saveland 
Citation: Saveland, J. 1995. Creating a Passion for Safety
vs. Management Oversight & Inspection. Wildfire 4(3):38-41.
I was disappointed with the OSHA
report of the South Canyon Fire. My feelings are not the
result of any need to defend my agency (USDA Forest Service). In another
time and place, I thought the OSHA report following the death of Bill
Martin (a smokejumper who died in a training jump) was right on target.
In that instance I was disappointed with my agency's response. But that
is not the case with this OSHA report. The bottom line is that the report
will not help prevent future loss of life. The report is a quick fix aimed
at what Argyris (1990) calls "single-loop learning" and is counterproductive
to creating a passion for safety.
The OSHA report did make some good points, for example, "OSHA further
supports the efforts of the agencies to address the more systemic issues
of suppression preparedness, fuels management, and the wildland/urban
interface. If those fundamental policy issues are not squarely addressed,
the safety and health of firefighters may be placed unnecessarily at risk."
However, there is a fundamental flaw in the OSHA report. To quote best
selling author Stephen Covey (1989), "the way we see the problem
is the problem." Covey talks about the difference between an inside-out
approach versus an outside-in approach. Inside-out is based on the premise
that between stimulus and response, people have the freedom to choose.
Effective change starts with individual choice and works outward. Covey
points out that the word responsibility--response-ability--is the ability
to choose our response. Juxtaposed to this concept is the widespread practice
in our litigious society of explaining our misery in the name of circumstance
or blaming someone else's behavior.
Fritz (1989) calls these two approaches to life the creative orientation
and the reactive-responsive orientation. The reactive-responsive orientation
(outside-in) is a way of living in which people predominantly react or
respond to circumstances that are beyond their direct control. In contrast,
the process of creating is taking action to have something come into being
(Fritz 1989). In the systems literature, the dichotomy has been framed
as the archetypal structure of addiction (Kim 1992):
The addiction archetype is a special case of "Shifting the Burden."
In both cases, a problem symptom is "solved" by applying a symptomatic
solution (B1), but the solution has a side-effect which diverts attention
away from the fundamental solution (B2). The side-effect (R3)--the dependence
on an external intervention--eventually overwhelms the original problem.
Argyris (1990) refers to a similar structure as single-loop and double-loop
learning. Single loop learning
(e.g. a thermostat) detects and corrects the immediate situation. Double-loop
learning solves the more basic problem of why the situation developed
by looking at the "master program," (also called "theories
of action," or "governing values"). If actions are changed
without changing the master programs individuals use to produce the actions,
then the correction will either fail immediately or will not persevere
An outside-in approach results in unhappy people who feel victimized,
powerless, and immobilized, who focus on the weaknesses of other people
and the circumstances they feel are responsible for their own stagnant
situation. Covey's and Fritz's research argues that the inside-out (creative)
approach is the most effective. Unfortunately, the OSHA report recommends
an outside-in approach. That is a fundamental flaw.
This is particularly disconcerting given the head of the Department
of Labor, Secretary Robert Reich. I had the opportunity to hear Secretary
Reich give an inspiring address to the 6th Annual National Conference
on Federal Quality, July 23, 1993. Prior to Secretary Reich's speech,
Peter Scholtes (author of The Team Handbook) pointed out that our top-down,
hierarchical organizations were rooted in the ideas of F.W. Taylor's "scientific
management" developed in the late 1800's. The hierarchical organizational
chart was designed to figure out who was at fault in train wrecks. He
called such a chart the tree of blame. Secretary Reich came on to point
out in great detail how such industrial-age thinking based on Taylor's
"scientific management" will not work in today's information-age.
Yet, here is this OSHA report that seeks to build a bureaucracy, the result
of which will be the ability to assign blame for "train wrecks,"
but will not prevent the wreckage.
Identifying the causal factor leads us in a particular direction. The
OSHA transmittal letter states, "we conclude that the primary cause
leading to the deaths of the fourteen firefighters was that no one person
was responsible for insuring the safety of the firefighters." Nonsense.
These were not rookie firefighters who needed someone to hold their hands,
baby-sit them, and "insure" their safety. These people were
hotshots and smokejumpers, type 1 crews, the best of the best. As I have
stated elsewhere (Dec. 94 Wildfire, p.63), the overriding causal factor
was: the firefighters did not recognize the seriousness of the threat
in time to take appropriate evasive action. They didn't see the danger
until it was too late. By asking the question why, this causal factor
leads us in the right direction. We get to start asking the questions,
how do firefighters recognize a threat? How do they communicate it? How
do they determine what is appropriate evasive action and when to take
it? Putnam (1995) states, "we lost firefighters on Storm King Mountain
because decision processes naturally degraded." By asking these questions
about decision processes and investigating their answers we start to make
some real improvements in firefighter safety. Stating the cause as "no
one person was responsible," as OSHA did, leads us on a counterproductive
search for blame that leads nowhere.
THE NINE UNSAFE CONDITIONS OR PRACTICES
The following review of the nine unsafe conditions or practices cited
by OSHA turns up a common theme of individual responsibility. As Putnam
(1995) states, "the goal should not be to fix blame. Rather, it should
be to give people a better understanding of how stress, fear and panic
combine to erode rational thinking and how to counter this process."
OSHA cited the following unsafe conditions or practices that led to the
1) "The identity of the Incident Commander was not effectively communicated
to firefighters." What does the identity of the Incident Commander
have to do with safety? This information is useful for assessing blame
for train wrecks, it does not prevent the wreckage.
2) "Adequate safety zones and escape routes were not established
for and identified to employees." The individual firefighter has
a responsibility to know their own safety zone and escape route.
3) "Available weather forecasts and expected fire behavior information
were not provided to employees." The individual firefighter has a
responsibility to obtain this information before stepping onto the fireline.
4) "Adequate fire lookouts were not used on the fire." Again,
it is up to the individual firefighter to take the initiative to ensure
there are fire lookouts.
5) "Hazardous downhill fireline construction was performed without
following established safe practices." The individual firefighter
has a responsibility to establish safe practices on the line.
6) "Management failed to provide the firefighters with comprehensive
fire behavior information." Again, the individual firefighter has
a responsibility to obtain this information before stepping onto the fireline.
7) "Management failed to ensure that the evolution of the Incident
Command System was commensurate with the fire threat."
8) "Management failed to heed the safety practices contained in
the Fireline Handbook pertaining to blow-up conditions.
9) "Management failed to conduct adequate workplace inspections
of firefighting operations, including on-site, frontline evaluations,
to ensure that established safe firefighting practices were enforced on
fires of all classes." Having a separate quality control bureaucracy
inspect for quality does not work. W. Edward Deming's third point of quality
states, "Cease dependence on mass inspection to achieve quality."
Deming reiterates the point in his eighth obstacle to quality, "quality
by inspection." The details of the limitations of inspection are
beyond the scope of this write-up. The interested reader can find plenty
of references in the voluminous literature on quality. Suffice it to say
that just as inspections won't produce quality, they won't produce safety
When I think about these nine conditions/practices, I am reminded of
factory workers on the shop floor who have the ability to shut down the
assembly line when quality is compromised. We need an analogous system
whereby the individual firefighter can shut down the system when safety
is compromised, not some archaic and ineffective system built around management
Safety, like quality, is everyone's job and responsibility, not something
that management provides. Several quality initiatives have failed because
they built a separate quality department. We can not afford the following
thinking: safety? that's not my job, that's management's job, or that's
the safety officer's job; quality? that's not my job, that's the quality
department's job. Ultimately, the individual is responsible for their
own safety. The OSHA report seeks to remove individual response-ability
and replace it with a system to assess blame. Such patriarchal, patronizing
systems will not work. It will only make matters worse.
OSHA's position is summed up by the concepts of management oversight
and inspection: "management of both agencies failed to provide adequate
oversight of the South Canyon Fire..." "To better protect firefighters
and prevent catastrophes such as the South Canyon Fire from recurring,
there must be an increased level of oversight on incident management."
In the agencies response to the OSHA report, there was a unanimous call
for developing a passion for safety:
Mike Dombeck: "...instill a passion for safety among all agency
Claudia Schechter: "...line managers must invest themselves in
assuring that everyone shares and practices a passion for safety in all
aspects of wildland fire activities."
Jack Ward Thomas: "...safety is the number one priority of our
firefighters." "...every employee must internalize."
As Fritz (1989) points out, "problem solving is taking action to
have something go away--the problem. Creating is taking action to have
something come into being--the creation. They are two fundamentally different
ways of thinking and acting. The bottom line is that the OSHA report,
by taking an outside-in approach based on oversight and inspection, works
against creating a passion for safety in each and every employee.
A DIFFERENT APPROACH
The OSHA report states: "A number of factors acted in cumulative
fashion to create and intensify hazards to firefighters on the South Canyon
Fire. Among those were a lack of adequate resources; dangerous weather,
fuel and terrain; failure to ensure that safe firefighting practices,
as outlined in the 10 Fire Orders, the 18 Watch Outs, and the Common Denominators
were implemented; a lack of a clear chain-of-command; and a lack of effective
management oversight." As Putnam states, "these tried-and-true
solutions simply fail to deal with a major cause of the fatalities."
We need to start looking outside the box. For examples of where we might
start looking, see the following: The Collapse of Sensemaking in Organizations:
The Mann Gulch Disaster (Weick 1993), Skilled Incompetence (Argyris 1986),
Overcoming Organizational Defenses (Argyris 1990), Creativity in Decision
Making with Value-Focused Thinking (Keeney 1994), and Dialogue: The Power
of Collective Thinking (Isaacs 1993).
"We lost firefighters on Storm King Mountain because decision
processes naturally degraded. At this time we do not have training
that give firefighters the knowledge to counter these processes. Both
the Investigation Team and Review Board recommended creating a passion
for safety but did not acknowledge that this passion is determined
by psychological and sociological processes. The type and skill level
team members and review boards (typically they include IMT personnel,
a fire weather forecaster, fire behaviorist, fuels specialist, equipment
specialist, but no psychologist or sociologist) predisposes them to
focus on the traditional inputs, which effectively excludes other
input, hence predetermining the outcome. This calls into question the
very process and structure by which we investigate fatalities and
the results to the fire community. We can and ought to do better."
(Putnam, in press)
If we are to make meaningful progress in improving firefighter safety
we must start investing in this type of research and training. To create
a passion for safety, we must learn about the creative process (Fritz
1989), effective actions (Covey 1989), meaningful dialogue (Isaacs 1993),
and organizational defensive routines (Argyris 1990). Not surprisingly,
all of this is at the foundation of what is increasingly becoming known
as "learning organizations" (Senge 1990).
Argyris (1990) provides a succinct summary:
It makes little sense to enact laws and rules against organizational
defensive routines, fancy footwork, and malaise. The equivalents of
such laws are already in place, and they do not work. The answer, as
in the case of prohibition, lies in each one of us becoming self-managing
and helping to create organizations that reward such self-responsible
actions. p. 161
In conclusion, after relating the story of Victor Frankl, a Jewish psychiatrist
imprisoned in the death camps of Nazi Germany, Stephen Covey wrote the
As Eleanor Roosevelt observed, "No one can hurt you without your
consent." In the words of Gandhi, "They cannot take away our
self respect if we do not give it to them." It is our willing permission,
our consent to what happens to us, that hurts us far more than what
happens to us in the first place. I admit this is very hard to accept
emotionally, especially if wehave had years and years of explaining
our misery in the name of circumstance or someone else's behavior. But
until a person can say deeplyand honestly, "I am what I am today
because of the choices I made yesterday," that person cannot say,
"I choose otherwise." (Covey 1989)
What's more important: assessing blame for train wrecks or choosing to
act responsibly and safely? You can't mandate a passion for safety, it
must come from the heart. The choice and responsibility is ours to make
individually; not OSHA, not management, not a safety officer, or anyone
1 Jim Saveland is a fire ecologist with the USDA Forest
Service, on the Forest Fire and Atmospheric Sciences Research Staff
in Washington D.C. Current address is Rocky Mountain Research Station,
Fort Collins, CO. The opinions expressed here are solely his own.
Argyris, C. 1986. Skilled incompetence. Harvard Business Review, 64(5):74-79.
Argyris, C. 1990. Overcoming Organizational Defenses. Prentice Hall,
Covey, S.R. 1989. The Seven Habits of Highly Effective People. Simon
& Schuster, New York.
Fritz, R. 1989. The Path of Least Resistance. Fawcett Columbine, New
Isaacs, W. 1993. Dialogue: The Power of Collective Thinking. The Systems
Thinker 4(3):1-4. Keeney, R.L. 1994. Creativity in Decision Making with
Value-Focused Thinking. Sloan Management Review 35(4):33-41.
Kim, D.H. 1992. Systems archetypes. Pegasus Communications, Inc., Cambridge.
Putnam, T. 1995. The Collapse of Decision Making and Organizational
Structure on Storm King Mountain. Wildfire 4(2):40-45.
Senge, P.M. 1990. The Fifth Discipline: The Art & Practice of the
Learning Organization. Doubleday, New York.
Weick, K. 1993. The Collapse of Sensemaking in Organizations: The Mann
Gulch Disaster. Admin. Sci. Quarterly 38:628-652.