Why was it that the SAIT and ADOSH investigators were able to interview BLM employees but unable to interview U.S. Forest Service employees to obtain critical Yarnell Hill Fire Human Factors information?
2019-06-20 | Arizona Desert Walker Joy A. Collura and contributing other(s)
Views expressed to "the public at large” and "of public concern"
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Figure 1. June 30, 2013, (left photo) 1645 hours (4:45 PM) and (right photo) 1648 hours (4:48 PM) photo comparison by WantsToKnowTheTruth of Blue Ridge Hot Shots (BRHS) and other wildland firefighters (WFs) and firefighters (FFs) and vehicles on the Yarnell Hill Fire (YH Fire) in the Ranch House restaurant parking lot with fire behavior and associated smoke columns in the background Source: Joy A. Collura records and Reporter Michelle Lee
Figure 2. June 30, 2013, 1712 hours (5:12 PM) Blue Ridge Hot Shots (BRHS) and other wildland firefighters (WFs) and firefighters (FFs) and vehicles on the Yarnell Hill Fire (YH Fire) in the Ranch House restaurant parking lot likely discussing the YH Fire and the GMHS and what to do next. Source: Tom Story
"Wisdom will save you from the ways of wicked men, from men whose words are perverse, who have left the straight paths to walk in dark ways, who delight in doing wrong and rejoice in the perverseness of evil, whose paths are crooked and who are devious in their ways." Proverbs 2:12-15 (NIV)
"Instruct the wise and they will be wiser still; teach the righteous and they will add to their learning." Proverbs 9:9
“The hardship of the exercises is intended less to strengthen the back than to toughen the mind. The Spartans say that any army may win while it still has its legs under it; the real test comes when all strength is fled and the men must produce victory on will alone.” (emphasis added) Steven Pressfield, Gates of Fire: An Epic Novel of the Battle of Thermopylae
The following paragraph contains some quotes from Geoffrey Regan's book (1995) titled Blue on Blue. A History of Friendly Fire. This is quite an apt reference to cover the YH Fire, since it experienced it's own style of "friendly fire" from a rogue, uncoordinated, uncommunicated firing operation in the Sesame Street and Shrine Corridor areas; the basic theme throughout the YH Fire Revelations website.
"While there have been many different reasons for individual accidents in battle, human error consistently has been present in all of them, and this is something that everyone - generals included - must learn to accept. ... Acceptance ... means coming to terms with the existence of the problem, rather than attempting to hush it up or sweep it under the carpet ... fog of war ... the authorities who swung into action, determined to cover up this tragic incident. ... Friendly fire was a fact of military life, yet civilians could not be expected to understand this. ... At moments like this did the truth really matter? ... so far none of them has been allowed to make it public knowledge. ... as the old saying ... in time of war, the first casualty is the truth. ... obvious conflict of evidence between the official report issued ... and the evidence given ... This conflict of evidence is so wide that one is left with no other conclusion than someone is lying as part of a coverup. ... The conflict of evidence ... indicates that a cloak of secrecy has been drawn over this particular incident. ... Certainly, the authorities have gone to some lengths to conceal details ... Nothing is gained by coverups except delay; the truth cannot be permanently suppressed. ... unprepared to release the full facts." pp. (3-21) (all emphasis added) Regan, G. (1995) Blue on Blue. A History of Friendly Fire. Avon Books.
Interviewing the BRHS would certainly clarify the "friendly fire" operation based on BRHS Brown's comment about someone burning themselves up, referring to the firing operation that was occurring on June 30, 2013? Clearly, all this documented research on "friendly fire" is a good reason to revisit Watch Out #7 "No communication link between your supervisor and Crew" because it drops off the "adjoining forces" prong specified in Fire Order #7 "Maintain prompt communications with your Crew, supervisor, and adjoining forces." As far as everyone was concerned, the GMHS had communicated to OPS that they were safely ensconced in "the black" and the "adjoining forces" knew that as well. Most WF supervisors would have fired off the Sesame and Shrine Corridor, because that is what it was designed for, and there was a 50 / 50 chance of success. However, every time one fires out, it must be communicated to others, especially your supervisor and Air Attack. Friendly fire was also experienced on the July 1949 Mann Gulch Fire on the Helena NF in Montana, being thoroughly researched by another truth seeker, Dr. Ted Putnam.
This post will cover a myriad of somewhat complex - yet very important - administrative, legal, and political issues surrounding the YH Fire and why the USDA USFS will not allow their employees (mainly the BRHS) to be subpoenaed or interviewed while the USDOI BLM allows it for their employees. It will also cover the ensuing YH Fire Serious Accident Investigation Team (SAIT), YH Fire Serious Accident Investigation Report (SAIR), AZ Department of Occupational Safety and Health (ADOSH), USFS and BLM investigations, employee interviews, employee rights, employee and investigator immunity, Touhy Regulations, Federal Housekeeping Statute, High Reliability Organizations, Human Factors, Staff Rides, missing evidence, and the necessary lessons learned from this epic tragedy in order to reduce the inevitable wildland fire fatalities that will likely occur if USFS employees (i.e. BRHS) are prohibited from being interviewed about what occurred on June 30, 2013. There are website / internet links to almost all of the references cited and / or examined and only three photographs and a few images.
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The USFS claims to be a High Reliability Organization (HRO) and has sponsored some credible, worthwhile research on the subject. Here is one of them. Black, A.E. and McBride, B.B. (2013) "Assessing High Reliability Practices in Wildland Fire Management: An Exploration and Benchmarking of Organizational Culture. Research Note RMRS-RN-55." ( https://www.fs.fed.us/rm/pubs/rmrs_rn055.pdf )
Across the board, the five HRO hallmarks to mindfulness are: (1) preoccupation with failure, (2) reluctance to simplify interpretations, (3) sensitivity to operations, (4) commitment to resilience, and (5) deference to expertise.
The USFS claims to be (or aspires to be) a High Reliability Organization (HRO) (i.e. naval aircraft carriers, air traffic controllers, electric and nuclear power plants, military organizations, wildland firefighting, etc. ), One would think the USFS would want to apply the preoccupation with failure prong in order to know as much as possible about the human factors that influenced those that died on fatality fires. And so, each of these five principles applies to the case in point here with why the SAIT and ADOSH investigators were able to interview BLM employees, but they were prohibited from interviewing the U.S. Forest Service employees (BRHS, AFUE study Group, and misc. other employees) to obtain critical Yarnell Hill Fire Human Factors information.
"FIGHTING THE FIRE IN OUR OWN HOUSE: HOW POOR DECISIONS ARE SMOLDERING WITHIN THE U.S. FIRE SERVICE" Cavnor, C.D. (2018) Naval Post Graduate School. The author is / was a Fire Lieutenant with the Dallas Fire Rescue Department in Dallas, Texas. The paper deals primarily with municipal and structural firefighting, however, it has a lot of research on James Reason's Swiss Cheese Model (active and latent pathways), "organizational deviance", the "normalization of deviance, HRO, drifting into failure, and more human factors research ( https://www.hsdl.org/?view&did=811369 ). Well worth the time to peruse his work because he refuses to mince words and goes into a lot of detail on these human factors issues. His listed subject terms are interesting enough: normalization of deviance, fire service, structural secrecy, drift into failure, satisficing, amoral calculator, loose coupling, Swiss cheese model, line of duty death, and escalation of commitment. However, it is a classic thesis consisting of a whopping 177 pages!
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To better understand some of the YH Fire questionable SAIT and its controversial SAIR, consider now a portion of what was previously posted on this website (July 15, 2018), from one of the alleged "investigators," titled: "Leave it alone ... you shouldn't go down this road ... let it be." How many times have you heard these same statements from others when mentioning the Yarnell Hill Fire?"
What follows are some comment excerpts from a May 19, 2016 Facebook (FB) post between Don Feser (former Angeles NF Fire Chief) critiquing and questioning the alleged YH Fire SAIT and ostensible "Investigator" Jay Kurth (USFS) while Kurth defends his / their actions and conclusions. The FB post thread (all emphasis is added) centers around a discussion of a May 19, 2016, InvestigativeMEDIA.com (IM) post titled: "Forest Service ignored information from hotshot leaders about Granite Mountain’s history of bad decisions" critical of the SAIT and SAIR. Only comments from Feser and Kurth are included here. The IM article in discussion is available in the link immediately below.
Don Feser: [discussing the above InvestigativeMEDIA article] "For what it's worth and my hunch is, that there's some truth behind it."
Don Feser: "Now that we're on a roll, who certified the GMHS in 2013, and who investigated the GMHS (firefighter fatality) incident on the 2013 Yarnell Fire? It's the obvious place to start, but findings thus far aren't credible."
Jay Kurth: "It was a learning review, not an investigation. They weren't findings. It was a statement of the story as best as could be put together from the information provided. We wrote specifically about the incident and what could be backed up with proof. It was as factually accurate as could be at the time. It was intentional to not draw suppositions or make bull shit assumptions about Marshes [sic] or Steeds [sic] thinking when it could not be backed up except with hindsight arrogance. Oh not everyone tells the whole story when asked either... (emphasis added)
[Jay Kurth continued]: "Does it make you feel better to bash the dead? Nowhere did the report explicitly say all choices were right. As I recall the words were something about no fault. Like a no contest plea. We left it up to firefighters to learn from what was written and provided some decision points where people could try and make sense of the choices that were acted upon and draw their own conclusions. All of you who relish in blame and revile (sic) in your own glory by bashing the system and slandering the review team should consider your own motivation. It certainly does not appear to be learning." (emphasis added)
It should be fairly obvious from Kurth's statements where these alleged "Investigators" drifted off to ... and it certainly was in all directions away from the truth.
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There is a statement that a Prescott FD FF makes in the video below that is unnerving to me, and certainly suggests the recognized hazardous attitude of Groupthink listed within the wildland fire NWCG Incident Response Pocket Guide (IRPG) on p. xii ( https://www.nwcg.gov/sites/default/files/publications/pms461.pdf ) with one of the statements the PFD FF makes about "brotherhood" and the actions of the GMHS if they could do it all over again. Some perspectives on the term and concept are then discussed follow.
"Team of 12 had sacred task of recovering bodies of fallen hotshots." Source: YouTube - ABC15 Arizona
( https://www.youtube.com/watch?v=GXYc0f_MIlQ&t=17s ) Published June 30, 2014
"There's a sense of brotherhood here that only Prescott firefighters, our guys, and it was only the right thing for us to be the ones to go up there. ... They're all heroes ... and they would do it all over again in a heart beat and I'm telling you right now they wouldn't change a thing. Prescott FD Fire Chief J.P. Vicente This mentality is what has been described as the Definition of Insanity and may even help explain the GMHS attitude and behavior on June 30, 2013..
It is important to address the contentious and equivocal "Brotherhood" issue among FFs and WFs, where it is claimed by some that we are not allowed to discuss bad things that happen to our "Brothers" in order to "protect them." On the contrary, I believe that we dishonor the dead (and the living WFs and FFs) by failing to talk about this particular epic, tragic fire and the 19 GMHS deaths. From a human factors lessons learned perspective, they are dead because they failed to recognize obvious fire weather and fire behavior indicators and failed to recognize, heed, and follow the Basic WF Rules (i.e. 10 & 18 & LCES).
No one is relishing in blame as Kurth asserted above; only coming to allowable conclusions based on the YH Fire IMT and GMHS faulty actions and fatal outcomes. The SAIT actions, decisions, conclusions and "the system" need to be called out with this type of shoddy, deceptive "investigation" and less-than-factual report writing. My motivation is, always has been, and always will be - The TRUTH. It's all about learning "complete" lessons - Learning the Truth.
The above is from my point of view and below is from a professional and academic perspective. "Brotherhood” is a phrase which possesses familial, military and religious connotations. "Constructing their identity as being part of a brotherhood can serve a very real purpose. Being in a family creates an intense bond between crew members. It implies a commitment which is more than just the performance of a task, and allows relationships of trust to emerge. The discursive construct of the brotherhood has very real effects for the work they do, in terms of opening up the relationship of trust between crew members. However, being in a brotherhood can equally bring its difficulties. Maintaining the bond may be regarded as being of higher priority than dealing with any problems which may emerge. It may be difficult to disagree with or speak out against any other crew member. Admitting a difference or the existence of a problem might be challenging for an individual. ... in some way connected to each other and separate to everyone else ... the concept of brotherhood created both a strong bond and boundary, and informed an identity which was unique to, but shared by, firefighters throughout the world."
O'Mahoney, J.M. (2012) Coping With Critical Incidents - A Critical Appraisal of Stress Management and Social Support Within the Retained Fire Service in Ireland. Univ. of East London Doctoral thesis
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This is an excerpt of an InvestigativeMEDIA (IM) post examining an "Our Investigation, Our Truth What Happened to the Granite Mountain Interagency Hotshots PODCAST (Deborah Pfingston - mother of deceased GMHS Andrew Ashcraft and former GMHS Doug Harwood) - Episode 08: Your Changes, Our Changes - Published: April 24, 2019
( https://anchor.fm/our-truth/episodes/Episode-8-Your-Changes--Our-Changes-e3qqcb ) Episode 8, Part 1 +0:48
Former GMHS Doug Harwood: We have a comment from a firefighter on a Hotshot crew in California. He says… “My crew was lucky enough to work with Blue Ridge last summer. On one of the slow days the Blue Ridge supe ( Brian Frisby ) took time to speak to our whole crew about the events of that day. Between THAT conversation, and listening to your podcasts, I’m appalled by the FAILURE of our original investigation. Not only was it an injustice to the perished firefighters, it’s a disservice to our current firefighters as well. How are we supposed to learn ANY lessons from the tragedy if we don’t know exactly what happened?”
it's interesting and encouraging that former BRHS Supt. Frisby is finally opening up about the YH Fire and sharing it with others. And that these WFs are then sharing it even further for others to see and benefit from.
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What follows is part of an email thread from Figure 2 below (April 12, 2016), between BRHS Supt. Brian Frisby, USFS Coconino NF employee Shelton LaVelle, and USFS Human Dimensions Specialist Joseph Harris regarding "Human Factors!" and the YH Fire Staff Ride. Frisby states that "the [YH Fire] picture that is being painted [for the Staff Ride] is very different than what we remember, the human factors that day were off the charts, [and] there was so much that went on that day that has been swept under the rug that may have affected the outcome." (emphasis added)
You may recall from an earlier post (October 15, 2018) that USFS Human Dimensions Specialist Joseph Harris wrote a research paper on Staff Rides and the USFS for his Master's Degree thesis from Lund University (Sweden) titled: "DO STAFF RIDES HELP MOVE THE FOREST SERVICE TOWARD ITS GOAL OF BECOMING A LEARNING ORGANIZATION?" (June 2, 2015) ( https://www.fireleadership.gov/toolbox/staffride/downloads/StaffRides_thesis.pdf )
In his dissertation's conclusion (p. 29), Harris writes: "Staff rides are highly valued learning products, and could contribute to the Forest Service’s mission to become a learning organization. Staff rides can easily be structured to conform to most of the suggested elements of a learning product. ... Research shows that accounting and allowing for a wide variety of learning styles within a presentation is more effective than tailoring a presentation to the self-described learning preferences of the students in the class. ... There is also a perceived gap between the traditional written report and the staff ride. The Forest Service can make progress toward its goal of becoming a learning organization by closing this gap through designing learning products that aim to replicate the emotional and intellectual impact of the staff ride to a much wider audience. ... There was a consensus that while we do a good job of identifying lessons to learn, we don’t do as good a job of actually following through with organizational change. ..." (emphasis added)
Harris' utilizes the classic application of understatement ( https://www.buzzfeed.com/expresident/greatest-understatements-of-all-time ) with this assertion: "There is also a perceived gap between the traditional written report and the staff ride." Really? Only a perceived gap? It's sure seems more like a gaping chasm. And whether "the Forest Service can make progress toward its goal of becoming a learning organization by closing this gap through designing learning products that aim to replicate the emotional and intellectual impact of the staff ride to a much wider audience ..." (emphasis added) is a well-established conclusion from current and former USFS employees - that they cannot and will not.
In my view, the USFS can, if they really want to, but will not ever achieve this goal because, according to USFS WFs still within the Agency, they will not allow their employees to publicly talk about the YH Fire and the GMHS in work-related wildland training academies, training sessions, and refresher courses unless and until they get "prior Regional and Washington Office approval." Moreover, it is even a taboo subject at the AZ Wildland Fire Academy each March in Arizona. I have been told that it is approved to talk about the actual SAIT-SAIR and its conclusions and discussion points but not ones' opinions or even "professional" opinions if it differs or strays in any way from the official "factual" SAIT-SAIR. My own YHFire eye-witness account was not accurately done and books have been made basing it out on the SAIR.
There is always supervisory discretion and supervisory approval, however, it certainly seems like some unconstitutional "prior restraint" with our First Amendment rights taking place here when WFs and FFs are prohibited from speaking about and / or fearful of speaking about the YH Fire tragedy - an event rife with valuable lessons learned. WFs and FFs and even citizens alike are starving for credible information about the YH Fire and what happened and why. There are only a few individuals and forums willing to research into it and discuss it (i.e. InvestigativeMEDIA.com, Academia.edu. www.yarnellhillfirerevelations.com, and to some extent, most recently, Our Investigation, Our Truth What Happened to the Granite Mountain Interagency Hotshots PODCAST (Deborah Pfingston - mother of deceased GMHS Andrew Ashcraft and former GMHS Doug Harwood) Your Changes, Our Changes - ( https://anchor.fm/our-truth/episodes/Episode-8-Your-Changes–Our-Changes-e3qqcb ). This will take you to their website with all ten links.
Notice that Pfingston's PODCASTS fail to address the YH Fire in a more open and honest way with "... Our Truth What Happened to the Granite Mountain Interagency Hotshots." As long as one agrees with their truth, you're just fine, otherwise watch out for their wrath.
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Wildfire fatalities continue to occur from the same causal factors because of “incomplete lessons learned.”
One way to address this is through credible Staff Rides, a valuable asset in the “lessons learned” tool box to reduce them, however, when based on deceptive “investigations,” how valuable are those “lessons learned?”
An overlooked NWCG Fireline Leadership statement includes that Staff Rides: “ … should avoid being a recital of a single investigation report. Such reports rarely address the human factors that affect individual decision-making. … providing participants with a variety of information sources is important. ” (emphasis added) The YH Fire clearly requires as many different “information sources” as possible to even come close to being factual.
Disturbingly, yet not surprisingly, these statements regarding other “information sources” and a “variety of information” will be changed completely in the newest version of this website below.
NWCG: Wildland Fire Leadership Development Program. The Staff Ride (2019). ( https://www.fireleadership.gov/toolbox/staffride/index.html )
Consider now the newest Staff Ride rendition regarding “information sources” mentioned above. “While an investigation report is a primary source of information, it should not be the only source of information that is used. Facilitators are encouraged to rent and watch the movie Courage Under Fire. Although this movie is a fictional drama, it provides a good perspective on the barriers that can be encountered during an incident investigation.” (emphasis added)
So then, we are encouraged to watch a fictional movie instead of knowing what actually happened and why on the YH Fire on June 30, 2013, instead of the USFS to allow Brian Frisby and the BRHS to be interviewed and find out from them instead, their first hand accounts. It's pretty evident that the entire BRHS Crew have a lot to share based on what former BRHS Supt. Frisby states above and below in his April 12, 2016, email and what the rest of the BRHS document in their unit logs and other notes posted elsewhere on this YH Fire Revelations website.
Figure 3. April 12, 2016, email thread (PDF image) between BRHS Brian Frisby Supt. and USFS Human Dimensions Specialist Joseph Harris regarding "Human Factors!" and the YH Fire Staff Ride. Source: Joy A. Collura
What follows are several (17 PDF image pages - Figures 4-4p) of an obscure, untitled paper with the topic sentence of: ("Responses by Mike Johns (with input from USDA OGC and others) to questions posed for the SAIT Course, 2008:") regarding legal authorities and legal opinions for some type of (in)formal training course (2008) by former AZ Assistant U.S. Attorney (AUSA) Mike Johns (RiP) on the subject of how USFS employees are to deal with Serious Accident Investigation Team (SAIT) investigations with inputs from the USDA Office of General Counsel (OGC) and USDOI Office of Solicitor. ( https://www.nifc.gov/PUBLICATIONS/acc_invest_march2010/speakers/ResponsesMJohns.pdf ) Some of the many topics covered are the various investigations and reviews, confidentiality, witnesses and cooperation thereof, immunity clauses, SAIT team member and employee responsibilities, and much more.
Figure 4. Legal authorities and legal opinions (PDF images) for some type of (in)formal training course (2008) by former AZ Assistant U.S. Attorney (AUSA) Mike Johns (RiP) on the subject of how USFS employees are to deal with Serious Accident Investigation Team (SAIT) investigations with inputs from the USDA Office of General Counsel (OGC) and USDOI Office of Solicitor. Source: GTS
Figure 4a. Legal authorities and legal opinions (PDF images) for some type of (in)formal training course (2008) by former AZ Assistant U.S. Attorney (AUSA) Mike Johns (RiP) on the subject of how USFS employees are to deal with Serious Accident Investigation Team (SAIT) investigations with inputs from the USDA Office of General Counsel (OGC) and USDOI Office of Solicitor. Source: GTS
Figure 4b. Legal authorities and legal opinions (PDF images) for some type of (in)formal training course (2008) by former AZ Assistant U.S. Attorney (AUSA) Mike Johns (RiP) on the subject of how USFS employees are to deal with Serious Accident Investigation Team (SAIT) investigations with inputs from the USDA Office of General Counsel (OGC) and USDOI Office of Solicitor. Source: GTS
Figure 4c. Legal authorities and legal opinions (PDF images) for some type of (in)formal training course (2008) by former AZ Assistant U.S. Attorney (AUSA) Mike Johns (RiP) on the subject of how USFS employees are to deal with Serious Accident Investigation Team (SAIT) investigations with inputs from the USDA Office of General Counsel (OGC) and USDOI Office of Solicitor. Source: GTS
Figure 4d. Legal authorities and legal opinions (PDF images) for some type of (in)formal training course (2008) by former AZ Assistant U.S. Attorney (AUSA) Mike Johns (RiP) on the subject of how USFS employees are to deal with Serious Accident Investigation Team (SAIT) investigations with inputs from the USDA Office of General Counsel (OGC) and USDOI Office of Solicitor. Source: GTS
Figure 4e. Legal authorities and legal opinions (PDF images) for some type of (in)formal training course (2008) by former AZ Assistant U.S. Attorney (AUSA) Mike Johns (RiP) on the subject of how USFS employees are to deal with Serious Accident Investigation Team (SAIT) investigations with inputs from the USDA Office of General Counsel (OGC) and USDOI Office of Solicitor. Source: GTS
Figure 4f. Legal authorities and legal opinions (PDF images) for some type of (in)formal training course (2008) by former AZ Assistant U.S. Attorney (AUSA) Mike Johns (RiP) on the subject of how USFS employees are to deal with Serious Accident Investigation Team (SAIT) investigations with inputs from the USDA Office of General Counsel (OGC) and USDOI Office of Solicitor. Source: GTS
Figure 4g. Legal authorities and legal opinions (PDF images) for some type of (in)formal training course (2008) by former AZ Assistant U.S. Attorney (AUSA) Mike Johns (RiP) on the subject of how USFS employees are to deal with Serious Accident Investigation Team (SAIT) investigations with inputs from the USDA Office of General Counsel (OGC) and USDOI Office of Solicitor. Source: GTS
Figure 4h. Legal authorities and legal opinions (PDF images) for some type of (in)formal training course (2008) by former AZ Assistant U.S. Attorney (AUSA) Mike Johns (RiP) on the subject of how USFS employees are to deal with Serious Accident Investigation Team (SAIT) investigations with inputs from the USDA Office of General Counsel (OGC) and USDOI Office of Solicitor. Source: GTS
Figure 4i. Legal authorities and legal opinions (PDF images) for some type of (in)formal training course (2008) by former AZ Assistant U.S. Attorney (AUSA) Mike Johns (RiP) on the subject of how USFS employees are to deal with Serious Accident Investigation Team (SAIT) investigations with inputs from the USDA Office of General Counsel (OGC) and USDOI Office of Solicitor. Source: GTS
Figure 4j. Legal authorities and legal opinions (PDF images) for some type of (in)formal training course (2008) by former AZ Assistant U.S. Attorney (AUSA) Mike Johns (RiP) on the subject of how USFS employees are to deal with Serious Accident Investigation Team (SAIT) investigations with inputs from the USDA Office of General Counsel (OGC) and USDOI Office of Solicitor. Source: GTS
Figure 4k. Legal authorities and legal opinions (PDF images) for some type of (in)formal training course (2008) by former AZ Assistant U.S. Attorney (AUSA) Mike Johns (RiP) on the subject of how USFS employees are to deal with Serious Accident Investigation Team (SAIT) investigations with inputs from the USDA Office of General Counsel (OGC) and USDOI Office of Solicitor. Source: GTS
Figure 4l. Legal authorities and legal opinions (PDF images) for some type of (in)formal training course (2008) by former AZ Assistant U.S. Attorney (AUSA) Mike Johns (RiP) on the subject of how USFS employees are to deal with Serious Accident Investigation Team (SAIT) investigations with inputs from the USDA Office of General Counsel (OGC) and USDOI Office of Solicitor. Source: GTS
Figure 4m. Legal authorities and legal opinions (PDF images) for some type of (in)formal training course (2008) by former AZ Assistant U.S. Attorney (AUSA) Mike Johns (RiP) on the subject of how USFS employees are to deal with Serious Accident Investigation Team (SAIT) investigations with inputs from the USDA Office of General Counsel (OGC) and USDOI Office of Solicitor. Source: GTS
Figure 4n. Legal authorities and legal opinions (PDF images) for some type of (in)formal training course (2008) by former AZ Assistant U.S. Attorney (AUSA) Mike Johns (RiP) on the subject of how USFS employees are to deal with Serious Accident Investigation Team (SAIT) investigations with inputs from the USDA Office of General Counsel (OGC) and USDOI Office of Solicitor. Source: GTS
Figure 4o. Legal authorities and legal opinions (PDF images) for some type of (in)formal training course (2008) by former AZ Assistant U.S. Attorney (AUSA) Mike Johns (RiP) on the subject of how USFS employees are to deal with Serious Accident Investigation Team (SAIT) investigations with inputs from the USDA Office of General Counsel (OGC) and USDOI Office of Solicitor. Source: GTS
Figure 4p. Legal authorities and legal opinions (PDF images) for some type of (in)formal training course (2008) by former AZ Assistant U.S. Attorney (AUSA) Mike Johns (RiP) on the subject of how USFS employees are to deal with Serious Accident Investigation Team (SAIT) investigations with inputs from the USDA Office of General Counsel (OGC) and USDOI Office of Solicitor. Source: GTS
What follows are a series of USDOI correspondence between the USDOI Office of Solicitor Agency and the AZ Department of Occupational Safety and Health (ADOSH) regarding "Request for Testimony Regarding the Yarnell Hill Fire" and "Interviews and Log(s)" and "Request for Interviews and Log(s)" and Touhy Request to Interview Rance Marquez and Dan Philbin and for Log(s)" and for "six listed individuals" USFS and USDOI BLM employees (Rance Marquez, Dan Philbin, Paul Lenmark, and Rusty Warbis) concerning their Agency Touhy regulations that deal with Agency records and employee interviews and testimony, and a RRR letter from USDOI NIFC to ADOSH attorney Christopher O. Anderson regarding ADOSH FOIA Request (FOIA FA 2013-13) for "all photographs of the Yarnell Hill Fire taken from the air by BLM employee Paul Lenmark." The BLM NIFC letter also states: "... we have enclosed a compact disc (CD) containing 47 photographs responsive to your request. All documents on the the CD are provided to you in their entirety," and Touhy Addendums addressing 13 questions
Figure 5. August 30, 2013, letter (PDF image) from USDOI Office of Solicitor Agency Counsel Alexandra Viscusi to AZ Department of Occupational Safety and Health (ADOSH) Safety Compliance Officer Marshall Krotenberg regarding "Request for Testimony Regarding the Yarnell Hill Fire" for both "six listed individuals" USFS and USDOI BLM employees (Lenmark and Warbis) and Touhy regulations that deal with Agency records and employee interviews and testimony. Source: Joy A. Collura
Figure 5a. Unknown date, out-of-sequence BLM FOIA Request (PDF image) page 2 response letter for all BLM signed by Howard Hedrick, Fire and Aviation, Acting Assistant Director NIFC for Peter J. Ditton, Fire and Aviation, another Acting Assistant Director NIFC. Source: Joy A. Collura
Figure 5b. Unknown date, BLM FOIA Request (PDF image) page 2 indicating the "cc" portion of the email to: Peter Ditton, Acting Asst. Director, Fire and Aviation; Tamara Neukam, Human Resources Officer, BLM NIFC; Brad Gibbs, Acting Group Manager, Aviation; John Glenn, Wildland Fire Operations.. Source: Joy A. Collura
Figure 6. September 6, 2013, email (PDF image) from Howard Hedrick to BLM Fire and Aviation NIFC BLM and cc to Alexandra Viscusi regarding Yarnell Hill Wildfire and the YH Fire SAIT and ADOSH investigators seeking information via interviews from BLM Fire and Aviation employees on the YH Fire. BLM policy and regulations concerning the same issues. Source: Joy A. Collura
Figure 7. September 6, 2013 email from ADOSH attorney Christopher O. Anderson to DOI attorney Alexandra Viscusi regarding: "Request for Interviews and Logs" requesting permission to interview several BLM employees that were engaged on the YH Fire (i.e. Rance Marquez, Dan Philbin, Paul Lenmark, Rusty Warbis) and their activity [Unit] Logs. And an addendum specific to each employee addressing the necessary 13 items of concern within the Touhy requirements for each witness and the Agency's interview requirements in the following figures below. Source: Joy A. Collura
Figure 8. September 6, 2013 email from ADOSH attorney Christopher O. Anderson to DOI attorney Alexandra Viscusi regarding Request for Interviews and Logs, Touhy Request Addendum for Rance Marquez addressing the necessary Touhy requirements per BLM policy and regulations. Source: Joy A. Collura
Figure 8a. September 6, 2013 email from ADOSH attorney Christopher O. Anderson to DOI attorney Alexandra Viscusi regarding Request for Interviews and Logs, Touhy Request Addendum for Rance Marquez addressing the necessary Touhy requirements per BLM policy and regulations. Source: Joy A. Collura
Figure 8b. September 6, 2013 email from ADOSH attorney Christopher O. Anderson to DOI attorney Alexandra Viscusi regarding Request for Interviews and Logs, Touhy Request Addendum for for BLM employee Dan Philbin addressing the necessary Touhy requirements per BLM policy and regulations. Source: Joy A. Collura
Figure 8c. September 6, 2013 email from ADOSH attorney Christopher O. Anderson to DOI attorney Alexandra Viscusi regarding Request for Interviews and Logs, Touhy Request Addendum for BLM employee Dan Philbin addressing the necessary Touhy requirements per BLM policy and regulations. Source: Joy A. Collura
Figure 8d. September 6, 2013 email from ADOSH attorney Christopher O. Anderson to DOI attorney Alexandra Viscusi regarding Request for Interviews and Logs, Touhy Request Addendum for BLM employee Paul Lenmark addressing the necessary Touhy requirements per BLM policy and regulations. Source: Joy A. Collura
Figure 8e. September 6, 2013 email from ADOSH attorney Christopher O. Anderson to DOI attorney Alexandra Viscusi regarding Request for Interviews and Logs, Touhy Request Addendum for BLM employee Paul Lenmark addressing the necessary Touhy requirements per BLM policy and regulations. Source: Joy A. Collura
Figure 8f. September 6, 2013 email from ADOSH attorney Christopher O. Anderson to DOI attorney Alexandra Viscusi regarding Request for Interviews and Logs, Touhy Request Addendum for BLM employee Rusty Warbis addressing the necessary the Touhy requirements per BLM policy and regulations. Source: Joy A. Collura
Figure 8g. September 6, 2013 email from ADOSH attorney Christopher O. Anderson to DOI attorney Alexandra Viscusi regarding Request for Interviews and Logs, Touhy Request Addendum for BLM employee Rusty Warbis addressing the necessary Touhy requirements per BLM policy and regulations. Source: Joy A. Collura
Figure 9. September 16, 2013 email (partial response) from DOI attorney John Gaudio with cc copies to Ray Suazo (BLM AZ State Director) and Kelly Castillo ((BLM AZ Fire Management Officer) to ADOSH attorney Christopher O. Anderson regarding "Touhy Request to Interview Rance Marquez and Dan Philbin and for Log(s)" and specific details on what is allowable. Source: Joy A. Collura
Figure 9a. September 16, 2013 email (partial response - page 2) from DOI attorney John Gaudio with cc copies to Ray Suazo (BLM AZ State Director) and Kelly Castillo ((BLM AZ Fire Management Officer) to ADOSH attorney Christopher O. Anderson regarding "Touhy Request to Interview Rance Marquez and Dan Philbin and for Log(s)" and specific details on what is allowable. Source: Joy A. Collura
Figure 10. November 1, 2013 ((BLM AZ Fire Management Officer) to ADOSH attorney Christopher O. Anderson regarding fulfilling the records requested. Source: Joy A. Collura
Now consider some more of the various research on human factors.
Addressing the human factors from and individual and an organizational level is important. Brazilian researcher Catino has concluded that when accidents happen in organizations, two different approaches are possible to explain the accident's origin and dynamics. The first approach, termed individual blame logic (IBL), is focused on finding those individuals that are to blame which satisfies a societal need to identify the guilty. The second approach, called organizational function logic (OBL) is focused on identifying the organizational factors that favored the event occurrence. In this second approach, it is believed that once these factors are removed, then either similar events cannot happen again or they will probably occur less frequently. His article compares the two different logics of inquiry, the consequences that result, especially those accidents caused by unintentional actions. The organizational function logic approach, favored by scientists is usually defeated by the individual blame logic. In a literature review, his article brings together the arguments for using the organizational function logic from the perspective that learning from accidents is necessary to prevent them from happening again.
A central aspect in this article is the measure in which both approaches give the possibility to learn from the accidents under investigation. The starting point for the IBL is the assumption that people make mistakes because they do not pay enough attention to the task they are doing. The OFL is based on the assumption that failure is part of the human condition, and if we cannot change the human condition, so then, the answer lies in the addressing the conditions under which humans' work can be changed (Reason. The organizational model views human error more as a consequence than as a cause (Reason, 1997).
Catino, M. (2008) A Review of Literature: Individual Blame vs. Organizational Function Logics in Accident Analysis. Journal of Contingencies and Crisis Management, 16.
Now consider some excerpts of more recent research derived from Catino's Organizational Myopia and how they relate directly to human factors and human failures and why it is / was so important to interview the USFS BRHS and what happened on June 30, 2013: Catino, M. (2013) Organizational Myopia. Problems of Rationality and Foresight in Organizations. Cambridge Univ. Press.
This quote sums up a lot of what occurred on many wildland fire fatalities and the YH Fire in particular during their 52 minutes of "discussing our options" and whether to finally leave their safety zone at the worst possible time: "An authoritarian and intuitive leadership that does not verify the rational implementation of objectives with colleagues, that is blind due to success achieved in the past and deaf to dissenting voices and warning signs, is in the sure prelude to disaster." (emphasis added)
One of the main remedies for the insidious Groupthink mentality is what is referred to in many circles as the "[D]evil's [A]dvocacy - in order to make the process of multiple advocacy more effective it is possible to institutionalize dissent. One assigns to someone the task of formulating even paradoxical interpretations to put to the test the validity of the points of view that have emerged and to prevent Groupthink." It may even be more reasonable to assign one for each Squad on a Crew.
The Israeli Defense Force (IDF) has a similar concept called the "10-Man Rule" where every tenth man performs this difficult, yet necessary, function.
How Israeli intelligence failures led to a ‘devil's advocate’ role. By Excerpt from Why Dissent Matters
Sun., May 21, 2017.
King Ori (2013) The Ten Man Rule. ( https://kingori.co/articles/2013/09/tenth-man-rule/ )
Anderson, P. (2016) The Tenth Man Principle. Aces Connection.
Consider now the issues of distorting our cognitions and generating false beliefs about the consequences of our decisions. Obscuring such consequences suppressing the awareness of the mind, inducing a weakness of will, as when we prefer options with worse consequences over options with better consequences inducing myopia, and modifying the weight of the decision in respect of the various consequences can become causal human factors adversely influencing WF and / or FF decisions and actions.
Columbia University researcher Jon Elster (2000), using the Tale of Ulysses as a backdrop, underlines how the effects of passion and emotions can produce a discrepancy between intention and behavior in various ways. Emotions can give rise to manifestations of wishful thinking (i.e. believing in what one desires) and self deception. These excerpts are right on in many ways to the GMHS in a virtual state of suspended time in their Safety Zone "lunch spot."
Elster, J. (2000) ( http://catdir.loc.gov/catdir/samples/cam032/99034103.pdf ) Cambridge Univ. Press.
"Additionally, the multi-fatality South Canyon (1994), 30-Mile (2001), and YH (2013) Fires shared a common element when the WFs disengaged to a designated Lunch Spot. In this setting, due to numerous physiological and psychological circumstances, (e.g., fatigue, stress, dehydration, alcohol-related impairment (hangovers), distractions, interruptions, etc.) - time essentially stood still. In each of these above noted tragic wildfires, when the WFs reengaged, they were evidently unmindful of basic wildland firefighting training and fire behavior markers which favored staying put. They were so engrossed with “discussing their options” of staying put or reengaging, they ceased observing more pressing tasks, like the rapidly changing weather."
Schoeffler, F.J. (2018) It Could Not Be Seen Because It Could Not Be Believed on June 30, 2013. AHFE ( https://link.springer.com/book/10.1007/978-3-319-94391-6 )
These effects of passion and emotions that Elster addresses sound just like the GMHS on the YH Fire on June 30, 2013, going all the way on all these key points. According to the official records, it was "52 minutes" from the YH Fire blowup to the GMHS burnover while the GMHS was engaged in what is commonly referred to as their "discussing our options" discreet Crew Net radio conversations between DIVS A and the Acting GMHS Superintendent on whether or not to disengage and leave their perfectly viable Safety Zone in the black at the worst possible time. Once again, the BRHS interviews would clarify why this occurred and made sense to the GMHS during this period of time on June 30, 2013, based on conversations and radio transmissions.
Figure 11. Image of historical U.S. fatality wildfires denoting time of blowup to time of burnover (Yarnell Hill Fire - 52 minutes) and "take 5 at 2" image for tactical pause and situational awareness. Source: WLFLLC and WFSTAR
Who do you think actually funded the Arizona State Forestry SAIT and the ensuing SAIR?
How about the USDA Forest Service? Curiously, however, and not surprisingly, the USFS funding the SAIT and SAIR issue came up in May 2019 based on recent comments by both YH Fire SAIT and ADOSH investigators. Even though Jim Karels (FL Forestry) was the designated Team Leader, it was very apparent to these men that both USFS Co-Leader Mike Dudley and USFS Vicki Christensen, former AZ Forestry Director, and then, Acting USFS Director, were the ones in charge and actually directing the investigation.
There has been a recent FOIA Request (2019-FS-WO-04116-F) filed for "All records (defined below*), including the applicable USDA USFS FOIA Index Log, created or obtained, regarding the June 30, 2013, Yarnell Hill Fire Serious Accident Investigation Team (SAIT) and related personnel and Yarnell Hill Fire Serious Accident Investigation Report (SAIR) for proposed, discussed, and / or actual funding by the USDA Forest Service (USFS)."
So then, now to answer the question of "Why was it that the SAIT and ADOSH investigators were able to interview BLM employees but unable to interview U.S. Forest Service employees to obtain critical Yarnell Hill Fire Human Factors information?" It should have become apparent with what you know because you were there, or because you were a SAIT or ADOSH investigator, or you had family, friends or loved ones that were there or know, or from what you have heard or read, that the USFS was simply following along what they have always done over the years regarding wildland fatality fires. Deception, lies, and normalization of deviance as well as the classic method of establishing a conclusion first and then finding the facts to fit that conclusion.
The USFS BRHS and the USFS Aerial Firefighting Utilization and Effectiveness (AFUE) Study Group have a significant amount of information of what occurred on June 30, 2013, in all manner of eyewitness testimony and other "Public Records" that would truly benefit the wildland fire community in the form of "complete" Lessons Learned, thus contributing to the means to lessen the continuing plague of wildland fire fatalities where they are killed by fire. The USFS has robbed us of these complete lessons learned by prohibiting certain U.S. Forest Service employees on the Yarnell Hill Fire from being interviewed.
We think about the 19 Granite Mountain Hot Shots every day and they inspire us to research and write. We publish this post today, June 19, 2019, to honor them on the day of the Granite Mountain Interagency Hotshot Crew (GMIHC) LEARNING AND TRIBUTE CENTER fundraiser. And we were cordially uninvited and refunded our money based on completely false allegations and assertions as they stated:
"Due to your history of disruptive behavior at other Granite Mountain Hotshot and wildland firefighting events, your published materials criticizing the Granite Mountain Hotshot crew, as well as your harassment of Granite Mountain Hotshot family members, we are refunding your ticket fees in full and are informing you that you and/or Joy may not attend the private showing of the movie or the fundraising event that follows."
"Kindest regards,
GMIHC Learning and Tribute Center Board
www.gmihc19.org"
The ADOSH investigation team were publicly critical and have voices, so then will they be shown the same as I saw this week and excluded from the fundraiser event? I will stay the course and keep focusing on training and unbiased "Human Factors" focused research. I am following the evidence to wherever it leads instead of foregone conclusions backed up with alleged facts. I think I should be shown professional respect in doing so. Our focus should be the monies raised for the cause and remember we are all on parallel paths for truth and honor and integrity. Hopefully, one day we all can find a common ground on the issues that are vital and important to both of us. Actually, all of us - Lives Matter! I simply wanted to attend the presentation just like any number of the public attending and I am being denied based on false allegations and misinformation and very false assertions of being disruptive and other stuff completely unrelated to their presentation that seem unfounded and not right.
And the only disruptions on fires were refusing unsafe assignments. We have never attended any Granite Mountain Hotshot events, so we cannot be held liable for something never attended. The published materials are criticizing the Granite Mountain Hot Shot Crew decisions and actions, never personal attacks. And unequivocally, never harassment of any Granite Mountain Hot Shot family member(s), only empathy and support.
It appears that "the Board's" decision was based on First Amendment issues unrelated to the alleged injustices asserted. It apparently had nothing at all to do with fundraising.
"The fear of the Lord is the beginning of knowledge; fools despise wisdom and instruction." Proverbs 1:7 (NIV)
"Iron sharpens iron, and one man sharpens another." Proverbs 27:17 (NIV)
"To receive instruction in wise dealing, in righteousness, justice, and equity;" Proverbs 1:3 (NIV)
Source: Staying the Course: Musings and reflections on A Course in Miracles Part One Kindle Edition by David Ian Cowan
EDITED: 6/20/19 9:05-9:33AZ Time- Friendly fire additions, Mike Johns paper link, Schoeffler paper link, minor punctuation and grammar corrections, and added "Acting" to USFS Director.
