1. ESCAPED PRESCRIBED BURNS: LESSONS WE SHOULD BE LEARNING Wisconsin Prescribed Burn Conference January 24-26, 2006

3. Objective s Not to point out “wrong decisions” on specific escapes. s Use events to see if there are common themes and/or “weak signals” occurring s Help you to avoid repeating others mistakes.

4. Information Sources s Prescribed Fire Lessons Learned: Escaped Prescribed Fire Reviews and Near Miss Incidents: by Deirdre Dether s Managing the Unexpected in Prescribe Fire and Fire Use Operations: RMRS-GTR-137. s The Nature Conservancy escape burn summary. s Wisconsin Department of Natural Resources files. s Escaped BLM, USFS, NPS, USF&W prescribed fire escape reviews.

5. Interesting Observation s Federal land management agencies complete 4000 to 5000 prescribed fires annually. With 98 to 99% conducted successfully (Dether). s Annually 40 to 100 federal escape events to learn from.

6. Wisconsin Definition of Forest Fire s “Forest Fire” means uncontrolled wild, or running fires occurring on forest, marsh, field, cutover, or other lands or involving farm, city, or village property and improvements incidental to uncontrolled, wild, or running fires occurring on forest, marsh, field, cutover, or other lands. [Wis. State Statue 26.01(2)] s State and non-governmental lesson learn events may be to 3-5% of total burns. –Maybe 25 to 45 near misses or escapes annually to learn from (based on 900 burns annually).

7. High Reliability Organizations (Managing the Unexpected) s Regard close calls and near misses as a kind of failure that reveals potential danger. s They pick up on these clues early-before they become bigger and more consequential. s Know small things that go wrong are often early warning signals of deeping trouble that provide insight into the health of the whole system.

8. High Reliability Organizations (Managing the Unexpected) s Treat near misses and errors as information about the health of their organization and try to learn from them. s Understand that if you catch problems before they grow bigger, you have more possible ways to deal with them.

9. After Action Reviews (AAR) s Reviews done are not rich in details. s Hard to obtain reports on escapes s No consistent frame work with common questions and documentation. s Reviews not widely distributed.

10. AAR Questions Asked s Is agency policy, guidance and/or direction adequate? s Was burn plan prepared and executed relative to agency policy? s Was the planning and execution of the prescribe burn done by qualified personnel?

11. Other AAR Observations s Most reviews did not evaluate the linkage of the environmental document to the burn plan. s All stopped at the point of looking at the actions beyond the escape. s Conclusion: –Agencies are not yet fully behaving as a learning organization – escapes and near misses are not systematically and routinely reported, evaluated, and shared.

12. Common “causes” contributing to escapes: s Surprise in Fuels and Fire Behavior s Surprise in Weather s Surprise in Communication and Coordination

13. Surprise in Fuels and Fire Behavior s Fuels did not act as Burn Bosses’ past experience told them it would. s Small pockets of fuel adjacent to fire line cause unexpected fire behavior problems. –Not included in burn plan –Acted as heat source and caused spotting

14. Surprise in Fuels and Fire Behavior s Greater than “normal” fuel loading due to: –Seasonal variation –Change in land management activities s Natural barriers did not check the spread or put fire out as planned.

15. Surprises in Weather s Drought conditions during or prior to the execution of the burn. s Previous increase in precipitation changed amount of fuel present. s Unexpected winds – strength, change in direction, and duration

16. Surprises in Communications and Coordination s Lack of proper notification and notification of adjoining landowners. s Lack of coordination and communications among key burn personnel. s Lack of coordination and communications with assisting/cooperating agencies. s Equipment breakdowns/failures at key times during burn execution.

17. Emerging “Blind Spots” Observed s Under rating burn complexity. s Incorrect selection of fuel models during burn plan development. s Start burn at upper end of prescription. s Test burn not in represented location. s Burn unit design not based on known fire behavior characteristics.

18. Commonalities of Prescribed Fires Declared Escapes s Vegetation-fuel complex surprises. s Spotting during ignition phase, or test fire. s Weather condition at upper and of prescription window. s Failure to adjust resources upward from minimums set in burn plan.

19. Not “Normal” Indicators s There is a pattern of below normal precipitation. s Received severity funding just prior to the burn. s Fire restrictions have just been lifted. s Hundred hour fuels are at or below critical levels. s Trend for dead and live fuel moistures are at or below long-term averages.

20. Conclusions s A consistent interagency framework to conduct escapes and near misses is needed. s NWCG rating system needs to include how to handle simultaneously lit burns. s Fuels and fire behavior are surprising us.

21. Conclusions s AARs need to be approached as a tool for learning. s Burn plan development needs to be a team approach. s Burn planners need to focus equally on: –Do not want to happen –Do want to happen s Agencies build supervisor “sensitivity into prescribed burn operations”.

22. “Go/No- It is easier to light a burn than not light one.” It is easy to let the “pressure to produce” override the signals indicating that a burn may not be best executed that day or even year.

23. Discussion