Risk Management 2007

Historic Trends Based on Safety Gram data - from : Based on Safety Gram data - from : 306 Individuals died in this 17 year period. 306 Individuals died in this 17 year period. Leading causes of death: Leading causes of death: Aircraft Accidents: 72 deaths, 23% Aircraft Accidents: 72 deaths, 23% Vehicle Accidents: 71 deaths, 23% Vehicle Accidents: 71 deaths, 23% Heart Attacks: 68 deaths, 22% Heart Attacks: 68 deaths, 22% 65% of these were volunteer firefighters 65% of these were volunteer firefighters Burnovers/Entrapments: 64 deaths, 21% Burnovers/Entrapments: 64 deaths, 21%

Historic Trends Federal - 73 deaths: Federal - 73 deaths: Burnovers: 39.7% Burnovers: 39.7% Aircraft Accidents: 19.2% Aircraft Accidents: 19.2% Heart Attacks: 13.7% Heart Attacks: 13.7% Vehicle Accidents: 11% Vehicle Accidents: 11%

Historic Trends – Conclusions 40% of federal fatalities were in burnovers 40% of federal fatalities were in burnovers Twice the number of the next highest category, aircraft accidents Twice the number of the next highest category, aircraft accidents Driving fatalities increased 107% from 1990 thru 1998 vs thru 2006 Driving fatalities increased 107% from 1990 thru 1998 vs thru 2006 Latter period included 3 multi-fatality driving accidents Latter period included 3 multi-fatality driving accidents Heart attacks are a lesser but still significant cause of federal firefighter deaths Heart attacks are a lesser but still significant cause of federal firefighter deaths

2007 Year in Review

2007 Forest Service events 2 Forest Service fatalities 2 Forest Service fatalities Both driving in Region 8 Both driving in Region 8 one returning from incident one returning from incident one returning from training one returning from training 22 entrapped firefighters 22 entrapped firefighters 6 burn injuries 6 burn injuries 4 fire shelters deployed 4 fire shelters deployed No heart attacks No heart attacks

Forest Service Entrapments 2007 Who became entrapped? Who became entrapped? Where did these entrapments occur? Where did these entrapments occur? In the WUI or elsewhere In the WUI or elsewhere What level of incident management was in place when the entrapments occurred? What level of incident management was in place when the entrapments occurred?

Who Became Entrapped Type of ResourceNumber of PeopleNumber of eventsPercentage of Total People Entrapped Engine Crew Personnel 11350% Overhead4318% Hotshot Crew Personnel 3114% Private Citizens219% Dozer Operator114.5% Contractor114.5%

Where Did Entrapments Occur? 25% in WUI situations 25% in WUI situations 75% outside the WUI 75% outside the WUI

Level of Incident Management 2007 Entrapments

Recommendations Figure out ways to reduce driving exposure Figure out ways to reduce driving exposure Emphasize use of seat belts Emphasize use of seat belts Emphasize proper use of PPE Emphasize proper use of PPE Maintain fitness programs and health screening Maintain fitness programs and health screening Firefit Firefit

Recommendations Maintain emphasis on entrapment avoidance Maintain emphasis on entrapment avoidance Use case studies and STEX Use case studies and STEX Focus firefighters on operational risk assessment Focus firefighters on operational risk assessment But don’t develop another checklist But don’t develop another checklist Engage your Incident Management Teams Engage your Incident Management Teams

Shifting Gears How do we know all the information just presented? How do we know all the information just presented? Why should we pay attention to “near miss” events? Why should we pay attention to “near miss” events? What are the best ways to learn from unintended outcomes? What are the best ways to learn from unintended outcomes?

Accident Pyramid H.W. Heinrich

Current Thinking Managing the Unexpected – Assuring High Performance in an Age of Complexity Managing the Unexpected – Assuring High Performance in an Age of Complexity Karl Weick and Kathleen Sutcliffe Karl Weick and Kathleen Sutcliffe High Reliability Organizing (HRO) High Reliability Organizing (HRO) Managing the Risks of Organizational Accidents Managing the Risks of Organizational Accidents Dr. James Reason Dr. James Reason “Swiss Cheese Model” “Swiss Cheese Model” Components of a ‘Safety Culture’ Components of a ‘Safety Culture’

Current Thinking The Field Guide to Human Error Investigations The Field Guide to Human Error Investigations Sidney Dekker Sidney Dekker Old view vs. new view of Human Error Old view vs. new view of Human Error

High Reliability Organizing HROs operate in high risk environments… HROs operate in high risk environments… …but they seem to have “less than their fair share of accidents” …but they seem to have “less than their fair share of accidents” Hallmarks of an HRO Hallmarks of an HRO Preoccupation with Failure Preoccupation with Failure Reluctance to simplify Reluctance to simplify Sensitivity to operations Sensitivity to operations Commitment to resilience Commitment to resilience Deference to expertise Deference to expertise

Latent Conditions  Excessive cost cutting  Inadequate promotion policies Latent Conditions  Deficient training program  Poor crew fitness Latent Conditions  Poor CRM  Mental Fatigue Active Conditions  Inadequate communications  Underestimated fire behavior Failed or Absent Defenses Organizational Factors Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts Accident & Injury Active versus Latent Failures (Reason, 1990)

Elements of a Safety Culture Four critical elements: Four critical elements: James Reason: Managing the Risks of Organizational Accidents James Reason: Managing the Risks of Organizational Accidents Reporting Culture Reporting Culture Just Culture Just Culture Flexible Culture Flexible Culture Learning Culture Learning Culture “A Safety Culture is one that allows the boss to hear bad news” Sidney Dekker “A Safety Culture is one that allows the boss to hear bad news” Sidney Dekker Bad news has to reach the boss Bad news has to reach the boss What exactly counts as “bad news”? What exactly counts as “bad news”?

Just Culture A culture of justice for self-reporting errors. An ethical workplace where people are encouraged (even rewarded) for disclosing errors and protected against reprisals for normative human error … regardless of outcome. James Reason James Reason

Human Error It has been estimated that 70-80% of all accidents involve some form of human error It has been estimated that 70-80% of all accidents involve some form of human error There are different types of human error: There are different types of human error: Decision error Decision error Skill-based error Skill-based error Perceptual error Perceptual error

Human Error “Human error is a consequence not a cause. Errors are shaped by upstream workplace and organizational factors….. Only by understanding the context of the error can we hope to limit its reoccurrence”. James Reason

Human Error and Investigations “….unlike the tangible and quantifiable evidence surrounding mechanical failures, the evidence and causes of human error are generally qualitative and elusive. Furthermore, human factors investigative and analytical techniques are often less refined and sophisticated than those used to analyze mechanical and engineering concerns.” FAA Report: Wiegmann and Shappell

Old View of Human Error Human Error is a cause of accidents Human Error is a cause of accidents To explain failure, investigations must seek failure To explain failure, investigations must seek failure They must find people’s inaccurate assessments, wrong decisions and bad judgments They must find people’s inaccurate assessments, wrong decisions and bad judgments Sidney Dekker

The “Bad Apple” Theory Complex systems would be fine, were it not for the erratic behavior of some unreliable people (bad apples) in them. Complex systems would be fine, were it not for the erratic behavior of some unreliable people (bad apples) in them. Human errors cause accidents; humans are the dominant contributor to more than two thirds of them. Human errors cause accidents; humans are the dominant contributor to more than two thirds of them. Failures come as unpleasant surprises. Failures are introduced to the system only through the inherent unreliability of people. Failures come as unpleasant surprises. Failures are introduced to the system only through the inherent unreliability of people. Sidney Dekker

New View of Human Error Human Error is a symptom of trouble deeper inside a system Human Error is a symptom of trouble deeper inside a system To explain failure, do not try to find where people went wrong To explain failure, do not try to find where people went wrong Instead, investigate how people’s assessments and actions would have made sense at the time, given the circumstances that surrounded them Instead, investigate how people’s assessments and actions would have made sense at the time, given the circumstances that surrounded them Sidney Dekker

New View of Human Error Human error is not a cause of failure. Human error is the effect, or symptom, of deeper trouble. Human error is not a cause of failure. Human error is the effect, or symptom, of deeper trouble. Human error is not random. It is systematically connected to features of people’s tools, tasks and operating environment. Human error is not random. It is systematically connected to features of people’s tools, tasks and operating environment. Human error is not the conclusion of an investigation. It is the starting point. Human error is not the conclusion of an investigation. It is the starting point. Sidney Dekker

What’s Wrong With This Picture? Why are reports that cite “violations” of the Standard Fire Orders meaningless? Why are reports that cite “violations” of the Standard Fire Orders meaningless? Why is the phrase “he or she lost situation awareness” meaningless? Why is the phrase “he or she lost situation awareness” meaningless?

Hindsight really is perfect! One of the most popular ways by which investigators assess behavior is to hold it up against a world they now know to be true. --Dekker One of the most popular ways by which investigators assess behavior is to hold it up against a world they now know to be true. --Dekker We match our hindsight of people’s performance with a procedure or collection of rules: We match our hindsight of people’s performance with a procedure or collection of rules: People’s behavior was not in accordance with standard operating procedures that were found to be applicable to the situation afterwards. People’s behavior was not in accordance with standard operating procedures that were found to be applicable to the situation afterwards.

But we don’t learn anything…. “The problem is that these after-the-fact-worlds may have very little in common with the actual world that produced the behavior under investigation. They contrast people’s behavior against the investigator’s reality, not the reality that surrounded the behavior in question. Thus, micro-matching fragments of behavior with these various standards explains nothing – it only judges.” --Sidney Dekker

What about “loss of situation awareness”? If you lose situation awareness, what replaces it? If you lose situation awareness, what replaces it? There is no such thing as a mental vacuum. There is no such thing as a mental vacuum. The only way to “lose awareness” is to become unconscious. The only way to “lose awareness” is to become unconscious. So….people didn’t lose awareness, rather the awareness that they had differed from reality. So….people didn’t lose awareness, rather the awareness that they had differed from reality. Why????? Why?????

People Create Safety Safety is never the only goal in systems that people operate. Safety is never the only goal in systems that people operate. Trade-offs between safety and other goals often have to be made under uncertainty and ambiguity. Trade-offs between safety and other goals often have to be made under uncertainty and ambiguity. Systems are not basically safe. People in them have to create safety by…adapting under pressure and acting under uncertainty. Systems are not basically safe. People in them have to create safety by…adapting under pressure and acting under uncertainty. Sidney Dekker

Doctrine and Culture How does it all fit together? Rule-based Culture: Rule-based Culture: Invariably found to be in violation of own rules in the event of an investigation Invariably found to be in violation of own rules in the event of an investigation Safety programs become more restrictive and compliance based Safety programs become more restrictive and compliance based Checklist saturation Checklist saturation Risk aversion in response to fear of liability Risk aversion in response to fear of liability

So What Is Doctrine? Doctrine is the expression of fundamental concepts and principles that guide planning and action. Principles are intended to help us develop the ability to make good choices. Principles are intended to help us develop the ability to make good choices. Principles need to be well stated to clearly represent our work, the environment, and the mission. Principles need to be well stated to clearly represent our work, the environment, and the mission.

Foundational Doctrine Guiding Fire Suppression The Operational Environment 1.The Forest Service believes that no resource or facility is worth the loss of human life. We acknowledge that the wildland firefighting environment is dangerous because its complexity may make events and circumstances difficult or impossible to foresee. We will aggressively and continuously manage risks toward a goal of zero serious injuries or fatalities.

On the practical side Doctrine provides a shared way of thinking about problems, but does not direct how problems will be solved. Rules exist, but in the context of Policy, laws and those items that are too important to leave to discretion, interpretation, or judgment.

On the practical side Doctrine allows firefighters to take risk successfully as opposed to restricting action considered to be risky through rules & checklists.

What is “Accountability” Is it the same thing as “punishment” Is it the same thing as “punishment” What types of things should people be punished for? What types of things should people be punished for? What does punishment accomplish? What does punishment accomplish? “Punishing is about stifling the flow of safety- related information (because people do not want to get caught)” -- Dekker “Punishing is about stifling the flow of safety- related information (because people do not want to get caught)” -- Dekker

Accountability Accountability should be based on a well defined distinction between acceptable and unacceptable behavior Accountability should be based on a well defined distinction between acceptable and unacceptable behavior The determining factor is not the act, but the intent of the actor The determining factor is not the act, but the intent of the actor Evaluation based upon understanding of intent, application of principles, and judgment Evaluation based upon understanding of intent, application of principles, and judgment

Learning and punishment don’t mix “A system cannot learn from failure and punish supposedly responsible individuals or groups at the same time.” --Sidney Dekker “A system cannot learn from failure and punish supposedly responsible individuals or groups at the same time.” --Sidney Dekker

True Safety Lies in Learning Learning is about seeing failure as part of a system. Learning is about seeing failure as part of a system. Learning is about countermeasures that remove error-producing conditions so there won’t be a next time. Learning is about countermeasures that remove error-producing conditions so there won’t be a next time. Learning is about increasing the flow of safety- related information. Learning is about increasing the flow of safety- related information. Learning is about…the continuous improvement that comes from firmly integrating the terrible event in what the system knows about itself. Learning is about…the continuous improvement that comes from firmly integrating the terrible event in what the system knows about itself.

We all make mistakes….. …..but how do we learn from them?

New Tools for Learning APA – Accident Prevention Analysis APA – Accident Prevention Analysis More formal, requires full team More formal, requires full team Carries assurance that no administrative actions will be taken if there was no “reckless behavior” Carries assurance that no administrative actions will be taken if there was no “reckless behavior” Written report produced that tells a story Written report produced that tells a story Includes recommendations Includes recommendations FLA – Facilitated Learning Analysis FLA – Facilitated Learning Analysis Less formal, may be a 3-person team Less formal, may be a 3-person team Written report may be produced Written report may be produced Sand Table Exercise often produced Sand Table Exercise often produced Does not include recommendations Does not include recommendations

SAFENET What SAFENET IS: What SAFENET IS: An anonymous reporting system where firefighters can voice safety and health concerns. An anonymous reporting system where firefighters can voice safety and health concerns. Documents corrective actions taken at the field level or provides suggested corrective actions for higher level of action. Documents corrective actions taken at the field level or provides suggested corrective actions for higher level of action. What SAFENET is NOT: What SAFENET is NOT: A forum for personal attacks/defamation. A forum for personal attacks/defamation. A mechanism to elevate “pet peeves”. A mechanism to elevate “pet peeves”. Only used for incidents that need higher level corrective action. Only used for incidents that need higher level corrective action. Interagency criteria established for posting determination – clearly stated safety and health issue necessary for posting. Interagency criteria established for posting determination – clearly stated safety and health issue necessary for posting.

Near Miss Reporting National submission decline from 2005: National submission decline from 2005: submissions submissions submissions submissions down to 119 submissions down to 119 submissions Every report matters!!! Every report matters!!!

Firefighters Need a Single Handheld Radio The M16 has been the standard infantry weapon for U.S. forces outside NATO since The M16 has been the standard infantry weapon for U.S. forces outside NATO since 1967.

Medical Standards Program Medical Standards Program SAFENET Administration SAFENET Administration FireFit FireFit Six Minutes for Safety Six Minutes for Safety WFSTAR – Fire Safety Refresher Training Website WFSTAR – Fire Safety Refresher Training Website Red Book lead for – Ch. 7 Safety, Ch. 18 Reviews and Investigations, portions of Ch. 13 Training & Quals, Ch. 15 Equipment Red Book lead for – Ch. 7 Safety, Ch. 18 Reviews and Investigations, portions of Ch. 13 Training & Quals, Ch. 15 Equipment NMAC coordination NMAC coordination

SHWT Update SHWT Update Energy, Nutrition, and Health Projects (MTDC): Energy, Nutrition, and Health Projects (MTDC): Wildland Firefighter Health & Safety Reports (publications) Wildland Firefighter Health & Safety Reports (publications) Nutrition Power Point & Brochure Nutrition Power Point & Brochure Shift Food Study Shift Food Study Hydration System Field Study Hydration System Field Study Revision of Fitness & Work Capacity Revision of Fitness & Work Capacity Boot Study Boot Study Powerline Safety Study Powerline Safety Study Requesting Seat Belt Study (human factors perspective) Requesting Seat Belt Study (human factors perspective) Other studies: PPE (gloves, pants, shirts), chain saw chaps, new Safety Zone research. Other studies: PPE (gloves, pants, shirts), chain saw chaps, new Safety Zone research.

SHWT Update SHWT Update New - Incident Emergency Medical Task Group - replaces Emergency Medical Support Group. New - Incident Emergency Medical Task Group - replaces Emergency Medical Support Group. Hazard Tree & Tree Felling Task Group Hazard Tree & Tree Felling Task Group Injury/Illness Module in ISUITE – input made by MEDL Injury/Illness Module in ISUITE – input made by MEDL Updating Agency’s Administrator Guide to Critical Incident Management Updating Agency’s Administrator Guide to Critical Incident Management