Part 1 of 9 - Underneath every simple, obvious story about ‘human error,’ there is a deeper, more complex story - a story about the system in which people work. Will these formerly unrevealed public records change the account of what occurred on June 30, 2013?
"But if serving the LORD seems undesirable to you, then choose for yourselves this day whom you will serve, whether the gods your ancestors served beyond the Euphrates, or the gods of the Amorites, in whose land you are living. But as for me and my household, we will serve the LORD." Joshua 24:1 (NIV)
Views expressed to "the public at large” and "of public concern"
DISCLAIMER: Please fully read the front page of the website (link below) before reading any of the posts ( www.yarnellhillfirerevelations.com )
The authors and the blog are not responsible for misuse, reuse, recycled and cited and/or uncited copies of content within this blog by others. The content even though we are presenting it public if being reused must get written permission in doing so due to copyrighted material. Our sincerest apologies for the delays. These posts were due out in August 2019 yet we had WIX.com website research a matter, and we are now finally able to rebuild the pages and make them "live." This extensive post may offend some due to the time of the year, however, we must stay the course to release information because more is yet to come out in future posts. To avoid such offense to some, please avoid further reading the posts until you find a proper reflective time for yourself. I did ask many people who were affected by this tragic Yarnell Hill Fire event and they said it was okay to post it this weekend. I know some people would not want any of this out at any time, yet I also know too many for "mental health" reasons need this out ASAP. Again - please avoid reading any further if you are unable to handle "sensitive material." Thank you.
To underpin and underscore pertinent issues in this post, we begin by addressing several important leadership and human factors issues discussed in the Serious Accident Investigation Team ( SAIT ) - Serious Accident Investigation Report ( SAIR ) and other publications and venues, many that are Yarnell Hill Fire (YH Fire) specific, prior to delving into the July 2019 Applied Human Factors and Ergonomics ( AHFE ) Conference images and issues presented in Washington, DC.
Figure 1. June 30, 2013, 1629 (4:29 PM) Yarnell Hill Fire image of very aggressive fire behavior taken from near the Ranch House restaurant in Yarnell along Hwy. 89 with the Weaver Mountains in the background. Source: Brian Lauber, WTKTT, Google Earth
This photo above is a key component for examining and discussing the YH Fire and Granite Mountain Hot Shots (GMHS) tragedy. As posted elsewhere on this website, the original photo (without Google Earth overlay) was given to the so-called Lead "Investigator" of the Serious Accident Investigation Team (SAIT) early on, however, it was never used or even referred to in the SAIT-SAIR. Instead, the SAIT-SAIR provided an "idealized image" on page 77 as "Figure 18" that gives a completely false representation of what actually occurred. The SAIT-SAIR falsely claimed that there was fire above and below the GMHS basically trapping them. Clearly, there is no fire visible above in this Figure 1 photo.
The title of this post, and the subtitle of our paper, are derived from a quote by Human Factors author and researcher Sidney Dekker in "Field Guide to Understanding 'Human Error" 3rd Edition, p. 5 (2006). “Underneath every simple, obvious story about ‘human error,’ there is a deeper, more complex story about the organization.” Dekker, in a subsequent research paper, talks about what this deeper more complex story and systems in what he refers to as "complexity and systems thinking" in his Lund University paper titled as a noteworthy question requiring a noteworthy answer: "In the system view of human factors, who is accountable for failure and success?" Dekker's research paper, along with over 30 other papers, is published within the Human Factors and Ergonomics Society Europe Chapter Annual Meeting in Linköping, Sweden, October 2009 book titled: "Human Factors - A system view of human, technology and organisation" is available in the links immediately below.
Dekker, Sidney. Human Factors: A system view of human, technology and organisation, Maastricht, the Netherlands: Shaker (2010). ( https://www.hfes-europe.org/books-human-factors-system-view-human-technology-organisation/ )
However, he does make this one debatable statement: "Formal, government-sponsored accident investigations enjoy this aura of objectivity and truth ..." (emphasis added) I disagree with this statement regarding government-sponsored investigations being objective and truthful. But then he may be talking about his own Government and certainly not our Government, which has a totally different impression of objectivity and truth, discussed in some detail in this post and elsewhere in other research papers and books, and on this website.
Dekker states: "The consequence for the ethics of failure is that there can be only one true story of what happened. In Newtonian epistemology, the “true” story is the one in which there is no more gap between external events and their internal representation. (i.e. those who, without any bias that distorts their perception of the world, will consider all the facts) are better poised to achieve such a true story." (emphasis added) In the system view of human factors, we are attempting to discover who is accountable for failure and success.
One of the primary goals of this website and these posts will always be to continually seek clues to the human behavior that cost these 19 young men their lives on June 30, 2013. These are things we need to know even though we may not fully understand, and therefore "The search for truth implies a duty. One must not conceal any part of what one has recognized to be true." Albert Einstein
Consider now the Part 1 of 5 posts, each consisting of a PDF (converted to JPEG) of our original "Formerly Unrevealed Public Records Should Change the Account of What Occurred on June 30, 2013. Underneath every simple, obvious story about 'human error.' there is a deeper, more complex story ... a story about the system in which people work" Power Point presentation. The PDF JPEG post differs from the originally published paper included in this link, in that it contains much more detail on each of the topic areas, especially the Sesame Street and Shrine Fuel / Fire Break Corridor area firing operation.
The presentation was given at the Applied Human Factors and Ergonomics ( AHFE ) 2019 International Conference jointly within the sub-conference on the 3rd International Human Error, Reliability, Resilience, and Performance, July 24-28, 2019, Washington D.C., USA . (http://www.ahfe2019.org/files/AHFE2019_FinalProgram.pdf )
Figure 2. PDF JPEG image of Title slide "Formerly Unrevealed Public Records Should Change the Account of What Occurred on June 30, 2013. Underneath every simple, obvious story about 'human error.' there is a deeper, more complex story ... a story about the system in which people work." Source: Schoeffler, Honda, Collura, Dekker
The 2019 AHFE Conference paper with the same title is published within the Advances in Human Error, Reliability, Resilience, and Performance group. Included in these PDF conversions are more details about whether there truly was a Sesame Street and Shrine Corridor Firing Operation area. ( https://link.springer.com/book/10.1007/978-3-030-20037-4 ).
"How liars create the 'illusion of truth.' Repetition makes a fact seem more true, regardless of whether it is or not. Understanding this effect can help you avoid falling for propaganda, says psychologist Tom Stafford. ... 'Repeat a lie often enough and it becomes the truth, is a law of propaganda often attributed to the Nazi Joseph Goebbels. If repetition was the only thing that influenced what we believed we'd be in trouble, but it isn't. We can all bring to bear more extensive powers of reasoning, but we need to recognize they are a limited resource. Our minds are prey to the illusion of truth effect because our instinct is to use short-cuts in judging how plausible something is. Often this works. Sometimes it is misleading. Once we know about the effect we can guard against it. Part of this is double-checking why we believe what we do – if something sounds plausible is it because it really is true, or have we just been told that repeatedly? This is why scholars are so mad about providing references - so we can track the origin on any claim, rather than having to take it on faith. But part of guarding against the illusion is the obligation it puts on us to stop repeating falsehoods. We live in a world where the facts matter, and should matter. If you repeat things without bothering to check if they are true, you are helping to make a world where lies and truth are easier to confuse. So, please, think before you repeat." (emphasis added) BBC Future. Psychology. Tom Stafford. 26 October 2016 (http://www.bbc.com/future/story/20161026-how-liars-create-the-illusion-of-truth )
Wildland firefighting is often likened to a type of warfare and its firefighters as warriors, so a brief discussion of a very unique warrior culture follows.
"Out of every one hundred men, ten shouldn't even be there, eighty are just targets, nine are the real fighters, and we are lucky to have them for they make the battle. Ah, but the one, one is a warrior, and he will bring the others back." - Heraclitus (534-474 B.C.) (emphasis added)
The Spartan army was comprised of citizens trained in the disciplines and honor of a warrior society and stood at the heart of the Spartan state; young men subject to increasingly intense military drill from early manhood to become one of the most feared warrior nations in the Greek world. At the height of their power being labeled as lacking vigor was cause for shame and ridicule. (History Channel - Sept. 1, 2018) (https://www.history.com/new/8-reasons-it-wasnt-easy-being-spartan) (Gates of Fire - S. Pressfield) (http://171.c92.mwp.accessdomain.com/book/gates-of-fire/)
This rigorous training was indeed necessary for times like these: “There was an exercise we of the battle train practiced when we served as punching bags for the Spartan heavy infantry. It was called the Oak because we took our positions along a line of oaks at the edge of the plain of Otona, where the Spartiates and the Gentleman-Rankers ran their field exercises in fall and winter. We would line up ten deep with body-length wicker shields braced upon the earth and they would hit us, the shock troops, coming across the flat in line of battle, eight deep, at a walk, then a pace, then a trot and finally a dead run. The shock of their interleaved shields was meant to knock the breath out of you, and it did. It was like being hit by a mountain. Your knees, no matter how braced you held them, buckled like saplings before an earthslide; in an instant all courage fled our hearts; we were rooted up like dried stalks before the ploughman’s blade.” (emphasis added) (Gates of Fire - Steven Pressfield)
"Although extraordinary valor was displayed by the entire corps of Spartans and Thespians, yet bravest of all was declared the Spartan Dienekes. It is said that on the eve of battle, a native of the district appeared in camp spreading alarm by his report of the numbers of the Persian archers. So vast were these myriads, the scout declared, that when they fired their volleys, the mass of arrows blocked out the sun. Dienekes, however, quite unfazed by the prospect of dueling such multitudes, remarked only, 'Let the Persians hide the sun; we’ll fight them in the shade.'” (emphasis added) (Pressfield)
Wildland Firefighters are certainly NOT Spartan warriors. However, it is always good to compare and contrast the leadership and work ethic traits of all types of military warriors to WFs and FFs that engage in the quasi-military realm of wildland firefighting.
Consider now Part 1 of 5 posts, each consisting of a PDF (converted to JPEG) of our original "Formerly Unrevealed Public Records Should Change the Account of What Occurred on June 30, 2013. Underneath every simple, obvious story about 'human error.' there is a deeper, more complex story ... a story about the system in which people work" Power Point presentation. The PDF JPEG post differs from the originally published paper included in this link, in that it contains much more detail on each of the topic areas, especially the Sesame Street and Shrine Fuel / Fire Break Corridor area firing operation. The presentation was given at the Applied Human Factors and Ergonomics ( AHFE ) 2019 International Conference jointly within the sub-conference on the 3rd International Human Error, Reliability, Resilience, and Performance, July 24-28, 2019, Washington D.C., USA .
Figure 3. PDF JPEG image of Introduction and major elements to be discussed slide. Source: Schoeffler, Honda, Collura
This is the basic outline of our Washington, DC AHFE PowerPoint presentation and this Part 1 to 5 Formerly Unrevealed Public Records post will follow it as closely as possible with additions and variations.
Figure 4. PDF JPEG image of Fairly standard Disclaimer promoting Lessons Learned and Entrapment Avoidance for WF and FF safety, noting the "authors' views," the use of "anonymous-by-request' contributors, and warning that some content may be considered by some to be graphic, disturbing, and / or offensive. Source: Schoeffler, Honda, Collura
Figure 5. PDF JPEG image of Arizona map (left) and Google Earth detail image (right) depicting Sesame Street and Shrine Corridor, upslope orientation, twin parallel chutes and chimneys in alignment with the GMHS Deployment Zone. Source: Schoeffler, Honda, Collura
You are encouraged to focus on this Google Earth image in Figure 5 a lot because it will become very useful (and necessary) as you read down through the post viewing the numerous photographs and videos of separate and distinct smoke columns (plumes) from the likely firing operation that occurred in the Sesame Street and Shrine Fuel / Fire Break Corridor area.
From a purely Fire Weather perspective, it is a permissible inference to state that, most experienced WFs, FFs, and Supervisors would find it interesting and informative that the motto for Yarnell is "Where the Desert Breeze Meets the Mountain Air." I say this because the way the Yarnell Hill Fire burned on June 30, 2013, was indicative of that type of desiccating and driving, hot desert air influence on the fire behavior on many wildland fires in Arizona, but especially on this tragic fire. This unique local fire weather factor (Watch Out # 4) is addressed in the July 2013 USA Today article below. And from a purely human factors perspective, it sure seems that the local GMHS were actually unfamiliar with these local factors in their own response area, especially considering that they had worked on the Doce Fire a week before exhibiting aggressive fire behavior.
The following is from a July 2, 2013, USA Today article titled: "Arizona officials seek answers after 19 firefighters die." "During the monsoon, the searing desert temperatures force columns of hot air high into the atmosphere, Leuthold and National Weather Service meteorologists said." On Sunday, meteorologists measured the thermals as high as 22,000 feet — halfway through the atmosphere. The readings were among the highest they’d ever seen. Brian Klimowski, the National Weather Service’s meteorologist in chief in the Flagstaff division, said local topography could channel winds into even stronger gusts, making fire behavior more unpredictable. ... The fire itself was a beast.“Guys on the ground told me the fire behavior was as extreme as anything they’d ever seen,” Dugger Hughes of the Southwest Coordination Center, an inter-agency organization in New Mexico said. ... What forensic pathologists will find will be important in learning how quickly the fire passed over the Prescott firefighters. ... “Charlie Gripp, a Federal Emergency Management Agency consultant and a former fire-operations safety officer for the U.S. Forest Service" said "they’ll go over all the qualifications, make sure there were no obvious over-sights by leadership,” he said. “They’ll look at the training they had: How good was it? Was it done timely and right? ... " (emphasis added) Source: "Arizona officials seek answers after 19 firefighters die" by Craig Harris, Sean Holstege and Bob Ortega, The Arizona Republic. Published 3:39 p.m. ET July 2, 2013 | Updated 4:08 p.m. ET July 2, 2013.
The fire weather was at its potential peak intensity for aggressive to extreme fire behavior based on the NWS observations, readings, and comments. And the comments made by Hughes (SWCC) and Gripp (FEMA) are instructive. Did the SAIT actually look into these detail areas and if so, how much consideration did they give them in their investigation and SAIR? I think it's fair to say - very little, if at all, because it's certainly not reflected in their "factual" SAIT-SAIR with the conclusion quoted below.
The idealized "Sunday's Shifting Winds" images from the link below reveal the intensity and time-frames of the June 30, 2013, YH Fire winds that occurred as a result of the approaching thunderstorm outflow winds. These winds fueled the fire with oxygen and funneled the fire through the deadly terrain mechanisms detailed below. The middle idealized image is most germane since the GMHS were burned over in their Deployment Site around 4:48 PM (1648). ( https://www.pulitzer.org/finalists/staff-181 ) Monday afternoon / evening to 5:29 p.m.: Reporter McKinnon reports further on how the weather played into tragedy, “When the weather changed,” he writes, “it turned a bad situation deadly.” "Wildfire experts: More than 1 factor spawned Yarnell tragedy Fuels, thunderstorm likely contributed to deadly fire condition" Shaun McKinnon The Republic | azcentral.com - Tue Jul 2, 2013 12:38 PM
I firmly believe "Forensic Weather" experts are the future for Wildland Fire Industry so we should "fact check" what the media places out to us.
Figure 5a. Idealized image of weather, respective wind shifts, wind speeds, and wind directions from 3:00 PM at 24 mph (left), 5:00 PM at 42 mph (middle) and 7:00 PM at 22 mph (right) Stanton, AZ remote weather station Source: Arizona Republic
Figure 6. PDF JPEG image of the Wildland Firefighting Rules (e,g, Ten Standard Fire Orders) and Guidelines (Eighteen Watch Out Situations). Source: Schoeffler, Honda, Collura
Based on dialogues with numerous WFs / FFs / USFS WFs and my research - they consistently stated immediately after the YH Fire, there began an intensive movement by many of the SAIT members, Subject Matter Experts (SMEs), and select U.S. Forest Service personnel to discredit these tried-and-trued Rules of Engagement. They visited numerous USFS Ranger Districts during their Critical and/or Refresher Training sessions, Wildland Fire Training Academies, Wildland Fire Apprenticeship Academies, and many other forums to discredit the "10 and 18" as being ineffective "because 19 men died." These USFS WFs were directed to consider the Ten Standard Fire Orders as "Guidelines" instead of Orders (the 18 Watch Out Situations are guidelines) and to focus only on the "official" SAIT-SAIR for information because the SAIT officially found "NO INDICATION OF NEGLIGENCE, RECKLESS ACTIONS, OR VIOLATIONS OF POLICY OR PROTOCOL.” (emphasis added) SAIR (2013) p. 4.
Bear in mind that the wise man David Hume once said: "In our reasonings concerning matter of fact, there are all imaginable degrees of assurance, from the highest certainty to the lowest species of moral evidence. A wise man, therefore, proportions his belief to the evidence." David Hume, (Enquiries Section X: Of Miracles; Part I. 87). I think he means that the strength of our beliefs should depend upon the strength of the evidence available or presented. Therefore, we should base our opinions on what and where the evidence (and the powers of our reasoning), guides us. And since most evidence leaves room for at least some doubt, we should always remain somewhat skeptical of what we believe.
Instructors at National USFS Wildland Fire Apprenticeship Academies, various quasi-private / municipal Wildfire Training Academies, and local USFS Ranger Districts were required to cite and utilize, and therefore, follow only the SAIT-SAIR "conclusions" and what is presented in the associated YH Fire SAIT PowerPoint and "briefing video." And USFS Apprenticeship Instructors were required to provide lesson plans for "Regional Office and Washington Office approval" if they were to discuss anything at all about the Yarnell Hill Fire.
These official "nationally recognized" and alleged self-proclaimed "progressive thinkers" used the fallacious argument based on the SAIT-SAIR no fault conclusion to boldly claim that the WF Rules don't work as evidenced by the nineteen dead GMHS. This deceptively insidious ploy continues to this day and is covered further in Figure 30 in Part 2 of 5 in this post and elsewhere on this blog.
Quotes from the following article (below) are pretty informative and insightful. Stephan Lewandowsky et al (2012)
Misinformation and Its Correction: Continued Influence and Successful Debiasing. Psychological Science in the Public Interest, 13. ( https://journals.sagepub.com/stoken/rbtfl/FNCpLYuivUOHE/full )
I will now take those quotes and "fill in the blanks" with [bracketed] relevant wildland firefighting words and phrases to make it germane to the wildland firefighting realm. The author also wrote a subsequent (2017) paper titled: "Beyond Misinformation: Understanding and coping with the post-truth era" on the same misinformation subject matter.
Consider first the original quote: "It is a truism that a functioning democracy relies on an educated and well-informed populace. (citation omitted) The processes by which people form their opinions and beliefs are therefore of obvious public interest, particularly if major streams of beliefs persist that are in opposition to established facts. If a majority believes in something that is factually incorrect, the misinformation may form the basis for political and societal decisions that run counter to a society’s best interest; if individuals are misinformed, they may likewise make decisions for themselves and their families that are not in their best interest and can have serious consequences." Lewandowsky et al (2012) (emphasis added)
Okay, so now let's consider the same logic when we put the above quote into a WFs perspective by "filling in the blanks" in bolded red. It is a truism that a functioning [wildland firefighting culture] relies on an educated and well-informed [pool of wildland firefighting resources]. The processes by which [these WFs and FFs] form their opinions and beliefs are therefore of obvious [human factors] interest, particularly if major streams of beliefs persist that are in opposition to established facts. If a majority believes in something that is factually incorrect, the misinformation may form the basis for [wildland firefighting tactical and strategic] decisions that run counter to a [wildland firefighting resource's] best interest; if individuals are misinformed, they may likewise make decisions for themselves and [those they are responsible for] that are not in their best interest and can have serious consequences.
Consider now the second quote on smoking: "... the persistence with which vested interests can pursue misinformation is notable: After decades of denying the link between smoking and lung cancer, the tobacco industry’s hired experts have opened a new line of testimony by arguing in court that even after the U.S. Surgeon General’s conclusion that tobacco was a major cause of death and injury in 1964, there was still “room for responsible disagreement.” (citation omitted) Arguably, this position is intended to replace one set of well orchestrated misinformation—that tobacco does not kill—with another convenient myth—that the tobacco industry did not know it. Spreading doubts by referring to the uncertainty of scientific conclusions—whether about smoking, climate change, or GM foods—is a very popular strategy for misinforming the populace." Lewandowsky et al (2012) (emphasis added)
Likewise, let's put the above into a WFs perspective by "filling in the blanks" with bolded red excerpts. "The persistence with which vested interests can pursue misinformation is notable: After decades of denying the link between [safe wildland firefighting by utilizing basic WF Rules and avoiding wildfire burnovers and fatalities], the [Wildland Fire Lessons Learned Center and upper-level wildland fire management] experts have opened a new line of testimony by arguing [in Two More Chain posts and Podcasts and the SAIT-SAIR Briefing Videos] that even after the [Wildland Fire Lessons Learned Center Honoring the Fallen video] conclusion that [following the 10 & 18 and WF Rules] was a major cause of death and injury in [all cases], there was still room for [luck decision conversations]. Arguably, this position is intended to replace one set of well-orchestrated misinformation—that [luck decision conversations] do not kill — with another convenient myth — that the [wildland firefighting culture that followed the Basic WF Rules, i.e. 10 & 18] did not know it. Spreading doubts by referring to the uncertainty of scientific conclusions —whether about [knowing and following the 10 & 18], climate change, [mega fires], or [political correctness]—is a very popular strategy for misinforming the populace [and the wildland firefighting resources and culture]."
"Old School" WFs and Hybrid FFs - and those that subscribe to the "Old School" concept - know that these Basic WF Rules work every time they are properly utilized and applied, hotly oppose the "Progressive Thinkers" and their use of the "Honoring the Fallen" as an emotional pretense. Worst of all, we dishonor the dead by not telling the truth about what contributed to and / or caused their deaths. I allege that it is because what they really want is to use smoke and mirrors and subtle deception to convince you that the GMHS did no wrong and that it could happen to anyone because the 10 & 18 have never worked. There are always going to be other WFs/ FFs/ Smokejumpers that believe that the Fire Orders are guidelines, and I have a respect for them but not their beliefs.
"OLD SCHOOL" MATTERS as much as it is to bridge it to the new current ways!
So then, even though I have had some private sector wildland fire training and experience and the Basic S-130 / 190 training, other than my time on the Weaver Mountains on June 28-30, 2013, I have never actually fought a wildfire. However, I struggled for years on InvestigativeMEDIA with Bob Powers and RTS when they posted that the "10 and 18" and LCES work all the time. I have said for years that one cannot always follow the Ten Commandments, so how can one always follow the "10 and 18" and LCES. Since then, in my research, I have been unable to locate even one wildland fire mishap and / or investigation report where they followed the "10 and 18" and LCES and were entrapped, deployed fire shelters, injured, or killed.
In 2002, Jerry Williams, the former Director of Fire and Aviation Management, USDA Forest Service, Washington Office, Washington, DC, wrote an article for Fire Management Today (Issue 62, pp. 31-35) that specifically addresses the value of the Fire Orders. What follows is based on remarks made by the him at the National Fire and Aviation Management Meeting from February 25 to March 1, 2002, in Scottsdale, AZ. It is most unfortunate that so many in the wildland firefighting culture have strayed far and wide from this sage counsel.
In other words, this germane wildland fire information and these valuable lessons learned that Mr. Williams offered in 2002, were clearly available to ALL WFs and FFs engaged in wildland firefighting in 2013, including the GMHS. Apparently, all others on the YH Fire that day followed Mr. William's sage advice. And literally tens of thousands of WFs and FFs engaged in wildland firefighting effectively and safely utilize them every single fire season. This is factual and NOT hindsight bias!
“Firm Rules of Engagement
“The Ten Standard Firefighting Orders must be firm rules of engagement. They cannot be simple guidelines, and they cannot be “bargained.” They are the result of hard-learned lessons. Compromising one or more of them is a common denominator of all tragedy fires. On the Dude, South Canyon, and Thirtymile Fires, the Fire Orders were ignored, overlooked, or otherwise compromised. (emphasis added) (Williams 2002) Unfortunately, many of today's WFs and FFs engaging in wildland firefighting do not subscribe to this professional advice. And worst of all, the Investigation Teams or Learning Reviews refuse to utilize these as a template or standard any longer.
“The Fire Orders mean little after we are in trouble. That is why we must routinely observe them and rely on them before we get into trouble. We know that no fire shelter can ensure survival all of the time under all circumstances. Entrapment avoidance must be our primary emphasis and our measure of professional operational success. (emphasis added) (Williams 2002) For "complete" lessons learned, the proactive "entrapment avoidance" training should be mandatory instead of the alleged "factual" SAIT-SAIRs of all the historical wildland firefighting mishaps - fatal and otherwise - that disingenuously and falsely conclude no fault, no blame, no violations of policy, protocol, or procedure.
“Conditions on the fireline can rapidly change. In the pressure of the moment, it is easy for people to overlook something important. That is why we must encourage our firefighters to speak up when they notice safety being compromised. As Weick and Sutcliffe point out, 'people who refuse to speak up out of fear enact a system that knows less than it must to remain effective. We must promote a working environment where even our greenest firefighters feel free to speak up." (emphasis added) (Williams 2002) The system is already in place to speak up, however, the actual results are mixed, inconsistent, and discouraging, thus promoting non-compliance.
“Following an accident, a “stand -down” should be an accepted practice for those involved, until the facts can be sorted out. However, it is a shame that our focus on accountability too often occurs after an accident. Culturally, we must shift the weight of accountability to the time before an accident takes shape. We must embrace the rules of engagement as a way of doing business—as a professional standard. Violation of any Fire Order must prompt management or supervisory intervention and, unless rapidly corrected, be unarguable grounds for release from the fireline, release from the incident, or - if egregious - serious personnel action. (emphasis added) (Williams 2002) Unfortunately, this "culture" has long been abandoned by management.
“However, we must not adhere to the Fire Orders for fear of punishment. We must embrace the Fire Orders because we owe it to one another. In that sense, the Fire Orders must become a shared obligation, where the leader’s situational awareness depends on participation by the entire crew and where the crew’s participation is tempered with respect for the leader’s responsibility. Borrowing from the aviation community’s model of Cockpit/ Crew Resource Management, we must focus fireline operations more on what is right than on who is right.” (emphasis added) (Williams 2002) This is basically the "Old School" way of wildland firefighting. And unfortunately, we fail to learn "complete" lessons because we are told that there was no blame, no fault, and no indications of any of these due to human factors.
And once again, the challenge is still out there to all you WFs and Smokejumpers and FFs engaged in wildland firefighting to provide even one wildland fire where the Fire Orders, LCES, were followed, and the 18 Watch Outs were utilized and mitigated, and a WF or FF was entrapped, deployed a fire shelter, or was killed by the wildfire.
This “FAILURES IN WILDLAND OPERATIONAL LEADERSHIP – 2006 through 2007” paper discusses, from an experienced USFS WF Supervisor's perspective, four wildland fires (including Little Venus Fire) from 2006- 2007 where “failures in judgment and faulty application of principles of fire suppression operations have been documented in review findings.” (emphasis added) He discusses the "incomplete" application of LCES, human factors, situational awareness (MOSTLY LACK OF), and leadership (or lack of) that result in unplanned, unanticipated burnovers and fire shelter deployments.
(http://www.fireleadership.gov/toolbox/staffride/local_staff_rides/alabaugh_canyon_fire/info_sources/r2_fam_entrap_briefing_paper_oct_2007.doc )
The following research paper is a fairly excellent one that was written by a USFS Smokejumper that turned academic. However, I disagree with at least this assertion: "It has been understood for some time that the number of firefighting rules and regulations imposed upon the line firefighter has become unwieldy." He then posits his, what I feel, quite complicated TEFF proposal as a viable replacement for the basic WF Rules.. Patrick Withen (2005) TEFF: THE TEN ESSENTIAL FACTORS IN FIREFIGHTING. Butler, B.W and Alexander, M.E. Eds. 2005. Eighth International Wildland Firefighter Safety Summit- Human Factors - 10 Years Later; April 26-28, 2005 Missoula, MT. The International Association of Wildland Fire, Hot Springs, SD. Patrick Withen is/was an Associate Professor of Sociology and Organizational Studies and Chair of the Dept. of Social Sciences at the University of Virginia at Wise, and was a Smokejumper for the U.S. Forest Service, out of McCall, ID. ( https://www.wildfirelessons.net/HigherLogic/System/DownloadDocumentFile.ashx?
DocumentFileKey=06446a2f-7dff-4fbe-8677-4032063067fd&forceDialog=0) Unable to hyperlink this one, so you'll need to cut and paste the link to locate it.
Wildland firefighting functions as a quasi military operation with both a vertical and horizontal chain of command, somewhat fixed formal and informal authorities and responsibilities, following orders, etc. There has been a favorable movement afoot, with some WF Supervisors, for some time now, delving into what is referred to as "shared leadership" covered in some of the papers listed below. Similarly, the Israeli Defense Force (IDF) "Tenth Man Rule" is well worth looking into. It advocates a "Devil's Advocate" role to counter the insidious known hazardous attitude of Group Think that is endemic to small, cohesive groups like military special operations and wildland firefighters.
( http://risingkashmir.com/news/the-10th-man-rule ) ( https://codeanddagger.com/news/2018/3/21/4-highlights-from-israels-secret-operation-in-syria ) Unfortunately, yet unsurprisingly, according to experienced WFs, there are NO research papers SPECIFICALLY that I know of on the subject of following or (dis)obeying orders dealing specifically with Wildland Firefighting. All are about and from a military perspective. Ask any experienced WF or FF engaged in wildland firefighting, and they will have at least one experience of "being shipped to Division Siberia" (somewhere the fire edge is out!) and/or being sent home for refusing an unsafe, illegal, immoral, or unethical order while offering more tenable alternative options.
Osiel, M.J. (1998) Obeying Orders: Atrocity, Military Discipline, and the Law of War. California Law Review Volume 86, Issue 5 Article 1.
( https://scholarship.law.berkeley.edu/cgi/viewcontent.cgi?article=1575&context=californialawreview )
Osiel wrote an excellent paper considering its age because he covers a lot of the history and background on the subject.
To Obey, or Not to Obey?
"So, to obey, or not to obey? It depends on the order. Military members disobey orders at their own risk. They also obey orders at their own risk. An order to commit a crime is unlawful. An order to perform a military duty, no matter how dangerous, is lawful as long as it doesn't involve the commission of a crime.
"You can’t just decide not to disobey an order because you don’t want to — you have to be confident that you are doing so in accordance with the ethics of your profession. And you had better be prepared to face the consequences if you are wrong." (emphasis added) What to Know About Obeying an Unlawful Military Order
"Military leaders must have the courage to speak truth to power and insist on access to the decision maker."
"'In war the first principle is to disobey orders. Any fool can obey an order. He ought to have gone on, had he the slightest Nelsonic temperament in him.' (emphasis added) So wrote First Sea Lord Jacky Fisher in angry critique of Capt. H.M. Pelly, a cruiser captain under Adm. Beatty at the Battle of Dogger Bank in 1915." When decision makers placed in these circumstances, they must accept the risk of audacity. This is an interesting historical narrative dealing with communications and human factors worth researching.
The wildland firefighting realm firmly endorses the "How To Properly Refuse Risk" with such sources as this: Refusing Risk (NWCG IRPG and 6-Minutes For Safety - July 2019) (https://www.nwcg.gov/committee/6mfs/refusing-risk)
Please recall that WFs and FFs must follow orders UNLESS they are: (1) Illegal; (2) Unsafe; (3) Unethical; or (4) Immoral. Stupid doesn't count. Often, however, WFs and FFs must follow "stupid orders" while staying within the safety realm of the WF Rules in order to prove the point that the orders are in fact stupid, a waste of time, effort, money, opportunity, and much more. Please take the time to read The Morality of Obeying Stupid Orders by John Reed. ( https://johntreed.com/blogs/john-t-reed-s-blog-about-military-matters/68973251-the-morality-of-obeyingstupid-orders )
Figure 7. PDF JPEG image of the classic Swiss Cheese Model by James Reason (Manchester, England) and directed generally toward the YH Fire and specifically to the GMHS. Source: Reason, Schoeffler, Honda, Collura
'The Swiss Cheese Model is frequently referred to and widely accepted in human factors circles. However, because there is no clear evidence that the Swiss Cheese metaphor is understood in the same way by all concerned, a brief refresher follows.
'The vertical Swiss cheese blocks indicate barriers within an organization and the holes within each block of your organization indicate weaknesses, so that when the holes line up, it means one weakness carried over into another weakness and so on, thus it creates a single hole throughout the organization with the potential to cause an accident.
'The idea of successive defense layers being broken down helps in understanding that things are linked within the system, and intervention at any stage - particularly early on - could stop a disaster from unfolding. Reason designed the model after years of in-depth research into the nature of accidents, which led him to the following insights:
'(1) Accidents are often caused by the confluence of multiple factors; (2) Factors can range from unsafe individual acts to organizational errors; (3) Many contributing factors to an accident are latent errors – they’re lying dormant waiting to be triggered by any number of active errors; and (4) Humans are prone to operational errors which require properly designed systems to mitigate the errors humans inevitably commit.'
Reason then determined that there were both active and latent failures, (i.e. the holes within the cheese). Other research indicates that nearly all adverse events involve a combination of these two sets of factors.
'Active Failures - Active failures or active errors are the unsafe acts committed by people. An example of an active failure would be an employee who chooses not to follow safety procedures like failing to wear sleeves rolled down on their fire shirts (PPE) while on the firelines. And worse yet, their supervisors setting a poor example by following suit with their sleeves rolled up and /or failing to comply with their supervisory responsibilities and failing to correct the infractions in the first place.
Latent Condition - Loosely equivalent to causal factor or contributing factor. Latent conditions or latent errors include contributory factors that lie dormant for days, weeks, months, or even years until they contribute to the accident. They are the failures built into procedures, systems, by the labor force or management. Latent conditions 'are failures waiting to be triggered by an active error'.
As stated above, an example of a latent condition would be supervisors failing to correct errant behavior or faults of those they supervise and ultimately responsible for their safety and welfare. If you combine this latent condition with the example of an active failure - failing to correct PPE safety infractions or failure to set a good leadership example wearing PPE - you eventually could get into a serious wildland fire accident.
The author points out that the Swiss Cheese Model does have a few weaknesses. He notes that it is great for looking backwards at ‘what caused the failure’, but of limited use for predicting failure(s).
Source: The James Reason Swiss Cheese Failure Model in 300 Seconds (May 30, 2018) by WhatsthePONT ( https://whatsthepont.com/2018/05/30/the-james-reason-swiss-cheese-failure-model-in-300-seconds/ )
Here is another research paper on the Swiss Cheese Model from a wildland fire perspective titled: "Use of Human Factors Analysis for Wildland Fire Accident Investigations" by Michele Ryerson and Chuck Whitlock for the Eighth International Wildland Fire Safety Summit, April 26-28, 2005 Missoula, MT.
Figure 8. PDF JPEG image of Arizona Rule 803. Exceptions to the Rule Against Hearsay - Regardless Whether The Declarant is Available. Article VIII. Source: Westlaw, Schoeffler, Honda, Collura
Due to the current lack of individuals willing to comfortably and safely come forward to openly share their first-hand accounts, the Exceptions to the Rule Against Hearsay are a major component concerning the firing operation that occurred on June 30, 2013. Other than the July 2013 video of the Sesame Street and Shrine Fuel / Fire Break Corridor area operations seen at the Yarnell, AZ Library, and later one on YouTube, witnessed by as many as twenty (20) individuals, including us, the two YH Fire Eyewitness Hikers, several experienced WFs and FFs, and local citizens, we must rely on hearsay evidence. First off - the video tape has disappeared and the YouTube video as well - gone without a trace, like so many other evidences related to the YH Fire.
Therefore, we highly encourage anyone and everyone that was involved in and / or photographed the likely Sesame Street and Shrine Corridor area firing operation to come forward and share their experience and any records you may have. Your anonymity is guaranteed and promised.
Likely, there were several individual WFs and FFs (Federal, State, and Municipal) that participated in the Sesame Street and Shrine Fuel / Fire Break Corridor area firing operations at multiple levels and capacities and in various sectors within this area, However, for the time being, they fear coming forward with their stories because of Agency regulations and statutes and / or policy, threats and intimidation from the various current and / or former Government employers and /or family members, friends, and loved ones.
This later included these individuals recounting their participation to others in other wildland fire forums when the YH Fire came up in discussions. These individuals also fear coming forward with their stories because of threats and intimidation from the various current and / or former Government employers and /or family members, friends, and loved ones.
Therefore, because of the dearth of individuals willing to comfortably and safely come forward to openly share their first-hand accounts of actual Sesame Street and Shrine Fuel / Fire Break Corridor area firing operations, we must instead rely on "Arizona Rule 803. Exceptions to the Rule Against Hearsay - Regardless Whether The Declarant is Available."
Below are the AZ and Federal statutes, as well as Law Review and legal articles on the Hearsay Exceptions subject that will better clarify what this rule means and how credible and essential the evidence is or may be to prove a key point. It is worthwhile to examine the CASEMINE examples that contain numerous legal precedential court cases from various States and Circuits throughout the U.S. as relevant examples.
(https://govt.westlaw.com/azrules/Document/N1331F4D0E7DB11E0B453835EEBAB0BCD?contextData=%28sc.Default%29&transitionType=Default ) This link must also be cut and pasted to find the document.
Arizona law basically mirrors the Federal Rules on this same subject as indicated in this Cornell Law School link.
Foster, T.E. (1979) Present Sense Impressions: An Analysis and a Proposal, 10Loy. U. Chi. L. J.299 ( http://lawecommons.luc.edu/luclj/vol10/iss3/3 )
CASEMINE Rule 803 Exceptions ( https://www.casemine.com/search/us?q=rule+803+exceptions )
Figure 9. PDF JPEG images of wildland fire investigations in general and the YH Fire SAIT in particular. Includes a Facebook thread between an experienced USFS WF Fire Supervisor and Jay Kurth, one of the lead YH Fire SAIT Investigators. Source: Schoeffler, Honda, Collura
Every time I read what SAIT Investigator Kurth says in Figure 9 above, from an alleged "leader" I feel nauseated. I hope the man is retiring soon, truly retired and stays away from the fire industry. We need honest investigators to talk about what happened and why instead of leaving it to the readers to come to their own conclusions. That shoddy work is unfair to the less experienced WFs and FFs.
Obviously, Mr. Kurth did not read the popular leadership book titled "Extreme Ownership" by former Navy SEALS Jocko Willink and Leif Babin. The book details that when you are the supervisor in charge of anyone, then you own every decision - no matter what. Additionally, it is well worth looking into the escaped Caples Prescribed (RX) Burn turned wildfire on the El Dorado NF (CA) in October 2019 in a major watershed that had experienced no fire since 1908. His USFS employees lit the hand-pile project KNOWING that Red Flag conditions were forecast with strong Cold Fronts days behind. Fire Order # 1 specifically covers those key areas. Check out the several Wildfire Today Caples (Prescribed Burn) Fire / Wildfire Archives articles (October 2019) in the link below on this very controversial, very preventable debacle, virtually unknown to most WFs, FFs, and certainly, the general public.
The Figure 9 (above) PDF JPEG image obviously indicates the focus of investigations are to find where people went wrong and why their actions seemed proper at that time, and utilizing the concept of Sensemaking - Why did it make sense for them to do what they did at the time? Unless, disingenuously, the investigation is to actually find no fault and no blame and no causal factors because, according to PFD Wildland Battalion (former Fire Chief) Chief Willis, "it was an accident, just one of those things that happens." Kurth called it a "Learning Review ... not an investigation" even though it is publically labeled as an "investigation" throughout AZ State Forestry records and archives.
Former USFS Human Factors investigator Dr. Ted Putnam, in his 2011 International Association of Wildland Fire ( IAWF ) research paper titled "Accident guides, Accidents, Stories, and the Truth" correctly points out how partial and predetermined these so called "investigations" really are. “Sometimes investigators deliberately distort or do not report all the causal elements which lead [wildland] firefighters to distrust the reports, hampering our efforts to stay safe." (all emphasis added) (YHFR website or Academia.edu or WLFLLC links)
Carrie Dennett, an Arizona State Forestry Division fire-prevention officer declined to say when the firefighters died. ... She said the state agency’s investigative team should begin taking shape today. “It will be designed so we can learn from this and teach up-and-coming firefighters, if there are any lessons that can be learned,” Dennett said. “A lot of firefighters died. We have to do this right and get the right team here. It will take some time.” (emphasis added) Say what? "IF there are any lessons that can be learned?" The "right team" - you mean like the team that will compliantly falsify data and establish a foregone conclusion(s)?
Consider the narrative that follows about an icon in investigative journalism and what he had to say about it.
Gerard O’Neill, Spotlight editor who defined investigative reporting in Boston, dies at 76 (Bryan Marquard Globe Staff, August 23, 2019, 10:58 a.m.)
Some 30 years ago, a Globe investigative reporter wondered how tough he should be in a story about corrupt judges, and sought guidance from Gerry O’Neill, editor of the Spotlight Team. “Write it so it scares you,” Mr. O’Neill said. (emphasis added)
“The greatest lesson we learned from him is this notion that when we go out to gather information, and run into all these obstacles, we will get frustrated,” Lehr added. “Gerry would say, ‘We just have to keep going. They think we’ll move on to the next story, but we’re not going away. We’ll do what we have to do.’ ” (emphasis added)
In the above referenced link for the Arizona Republic Pulitzer Award document they stated: " We filed nine public records requests to a half dozen local, state and federal agencies. Our demands included deployment logs, work schedules, command duties, training records and more. ... We were relentless. In the days immediately following, as the fire was contained, local officials cut off media access to Yarnell. This was not a safety issue, as utility workers and others were allowed in. This was an issue of media control. We fought aggressively, asserting our rights in the field and working with legal counsel to demand access through the county attorney’s office. ... After this story published, a county sheriff threatened to arrest any reporter found in town. We fought back hard, with reporters and photographers stand to intimidation from authorities as they continued to seek access. Ultimately, the road-blocks came down, but the fire-scene information available before then came only because of our team. ...
“You can talk about how wind shifts occur and maybe how the thunderstorms come overhead, but it’s a completely different thing when you’re there actually seeing it and experiencing it,” said Rick Swan, a retired deputy chief of the California Department of Forestry and Fire Protection. “When the wind starts changing direction, you see that. If you’re trained, you’re paying attention.
”Some of the procedures firefighting crews follow today grew out of the 1990 Dude Fire near Payson, which killed six firefighters when flames exploded amid a rapidly developing thunderstorm. The fire has been studied intently by fire experts and government agencies. The lessons drawn from it still guide wildland firefighting. ..
“Those things are ingrained in our head,” Swan said. “No matter where you’re at, you’re constantly re-evaluating your situation, the wind, the topography, the fuel types. You’re always reassessing where you are, where you have to be, the amount of time you have to get there, all to make sure you’re safe.”
And then there is the forever etched-in-our-mind conclusion from the self-proclaimed "factual" Yarnell Hill Fire Serious Accident Investigation Team (SAIT) and Serious Accident Investigation Report (SAIR): “NO INDICATION OF NEGLIGENCE, RECKLESS ACTIONS, OR VIOLATIONS OF POLICY OR PROTOCOL” (emphasis added) The SAIT also concluded that "the judgments and decisions of the incident management organizations managing this fire were reasonable, ..." (all emphasis added) (Sept. 2013) page 4.
So then, even citizens and other non-WFs or FFs, including WFs or FFs that work on wildland fires, ask this question because those conclusions are ever so incredulous: How is it possible to do everything right and yet kill 19 Hot Shots in one fell swoop?
"Why are the conclusions of the Yarnell Hill Fire investigation so timid?" by Cally Carswell Oct. 1, 2013. High Country News article, link here: ( https://www.hcn.org/blogs/goat/why-are-the-conclusions-of-the-yarnell-hill-fire-investigation-so-timid/ )
In this same High Country News article above the author states some disturbing, yet unsurprising facts: "Recently, [Wildfire Today author] Gabbert reports, federal guidelines for producing reports on these investigations were changed, likely out of fear of lawsuits. They now call for a public report detailing the factual information -- who went where and when -- but not drawing any "inferences, conclusions or recommendations." A separate report, not to be made public, would take those second steps. "The guide tells investigators to avoid analyzing whether basic fire-safety protocols were violated and to destroy draft documents after the inquiry is done," according to USA Today. Gabbert predicted that the new policy would result "in public reports that are much different from those we have seen in recent years," and would inhibit the public's and firefighters' ability to learn lessons that could prevent future fatalities. (all emphasis added)
Troubling indeed! This statement of the Government's actions and talk is rife with irksome doublespeak according to the U.S. Dept. of Justice talking about being the custodians of records (link below). How can one detail the "factual information" and then not draw any inferences, conclusions or recommendations if that is your duty as an assigned investigator? And why would you have a separate report, not to be made public, to take those second steps, unless you were concealing something? And to have the investigators "avoid analyzing whether basic fire-safety protocols were violated" makes absolutely no sense when these are the mainstay of safe and effective wildland firefighting as noted in some detail above ( Figure 6. ) in the Jerry Williams paper on the subject.
The destruction of draft copies mentioned above is akin to the California Division of Forestry (CDF and CalFire) tactic of labeling their "Red Sheet" (high-level investigation reports for the top tier of CDF management only) as "Drafts" which somehow excludes them from Records Requests. Additionally, this would preclude any and all investigative journalists and others their First Amendment right of speech and / or redress because there would be no historical, archive data.
And to actually "destroy draft documents after the inquiry is done" all but ensures that those of us that want and seek to know the truths of these matters will be forever forbidden from doing so. Several of these seem to be very clear violations of 18 U.S.C. §641 (taking of a public record or document is prohibited), 18 U.S.C. § 1361 (destruction of such records prohibited), 18 U.S.C. § 1663 (Protection Of Government Property - Protection Of Public Records And Documents), and 18 U.S.C. § 2071 (essentially three types of conduct are prohibited by 2071) (DOJ link below) according to the U.S. Dept. of Justice (DOJ), as well as a clear-cut violation of our First Amendment rights to seek redress. 18 U.S. Code § 1001. (Statements or entries generally ... whoever, in any matter within the jurisdiction of the executive, legislative, or judicial branch of the Government of the United States, knowingly and willfully - (1) falsifies, conceals, or covers up by any trick, scheme, or device a material fact; (2) makes any materially false, fictitious, or fraudulent statement or representation; or (3) makes or uses any false writing or document knowing the same to contain any materially false, fictitious, or fraudulent statement or entry ...) and 1663. Protection Of Government Property -- Protection Of Public Records And Documents. ( https://www.justice.gov/jm/criminal-resource-manual-1663-protection-government-property-protection-publicrecords-and )
I think it is a permissible inference that our SAIT Government officials, posing as alleged "Investigators," may be complicit (read "involved with others in an illegal activity or wrongdoing") in the above Federal 18 USC criminal violations (e.g. 18 U.S.C. § 641, 1361, 1663, 2071, 1001) involving the YH Fire Public Records in order to ensure that "we will never know" (mentioned SIX TIMES in the SAIT-SAIR) to buttress their forgone conclusion of finding: “NO INDICATION OF NEGLIGENCE, RECKLESS ACTIONS, OR VIOLATIONS OF POLICY OR PROTOCOL” (emphasis added)
Consider now this interesting, informative, and somewhat contentious Facebook thread concerning the YH Fire SAIT and SAIR with one of the SAIT "Investigators" trying to defend their actions. Well worth reading.
FACEBOOK account may be needed to search the FB archives for the following FB thread
To further clarify how the alleged YH Fire "investigation" was handled, it's as if YH Fire SAIT member Jay Kurth and the rest of the SAIT were strictly following the new Federal guidelines described above in the High Country News article. In a May 19, 2016, Facebook post, Don Feser, an experienced and well respected USFS Wildland Fire Supervisor with a post thread from SAIT Investigator Jay Kurth remarking on the SAIT-SAIR provides some newfound clarity and future focus:
Kurth posted: “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. … It was as factually accurate as could be at the time. It was intentional to not draw suppositions or make bullshit 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….” (all emphasis added)
Kurth posted: “Does it make you feel better to bash the dead? … We left it to the firefighters to learn from what was written … 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.” (all emphasis added)
On the contrary Mr. Kurth, our motivation is mainly truth-seeking, however, it also includes learning complete lessons from those truths. So then, SAIT "Investigator" Kurth, clearly appears to be outright ignoring the fact that the purpose of an investigation is to "to find where people went wrong and why their actions seemed proper at that time" while utilizing the concept of Sensemaking being true to their duty as "Investigators." Instead, it readily appears that Kurth relegates himself and the entire SAIT to the task of being mere "storytellers." And that places the onus on the readers and those interested in what actually occurred and why. As former Yarnell Fire Chief Pete Anderson (RiP) asked: "Why did they even have a SAIT in the first place if they are going to have that kind of approach?" (emphasis added)
Former Yarnell Fire Chief Pete Anderson (RiP) forthrightly stated in an Oct. 8, 2013, video interview (Figure 33 in Part 2 of 5) regarding the alleged SAIT "investigators" and "investigation" making several statements and asking many questions that deserve answering: And whitewash that there was no wrongdoing on anybody's part as far as the report went but we're not here to point fingers. Well what are you here for? You're investigators. Investigators are supposed to investigate. They're supposed to point fingers. They're supposed to say 'what [it] is that had happened. ...'" (emphasis added)
_____________________________________________________
Consider now "The Self-Fulfilling Prophecy" of the Fatalistic SAIT Rhetoric of "we will never know."
"A self-fulfilling prophecy refers to the phenomenon of making a prediction or expectation of something and this “prediction” becomes true because "of one belief that it will." ... and behaved in a manner that created this. This suggests that a person’s belief can influence their actions. The principle of this phenomenon is that people create consequences regarding people or events, based on their previous knowledge towards that specific subject. Additionally, self-fulfilling prophecy can be applied to negative and positive outcomes." (emphasis added and footnote omitted) ( https://en.wikipedia.org/wiki/Selffulfilling_prophecy )
Fear not because there is a viable successful solution to this dangerous attitude at the conclusion of the Self-Fulfilling Prophecy section (i.e "Psychological Reactance Theory")
Figure 10. PDF JPEG image SAIT-SAIR 'We will never know ...' Why not" followed by a quote from a YH Fire SAIT Subject Matter Expert (SME) to an experienced WF supervisor in August 2013 regarding "all the evidence that we have that we cannot and will not ever release” about theYH Fire and the GMHS. And six (6) SAIT-SAIR quotes confidently asserting that "we will never know" any of the details surrounding the who, what, when, where, and why surrounding the GMHS deaths. Source: Schoeffler, Honda, Collura
Ominously, it is significant to note that an experienced, high level former USFS WF Supervisor serving as one of the many YH Fire SAIT Subject Matter Experts (SME) made this revealing remark to a contributing author in August 2013: "We have so much evidence that we cannot and will not ever release” about the YH Fire and the GMHS. This illuminating, yet disturbing, SME statement shows me that the SAIT's sinister plan was intended for their supposed "we will never know" investigation focus and what follows below. It is addressed in some detail in Figure 59. titled: "Unaccounted for YH Fire and GMHS evidence" in Part 3 of 5 of this post.
Additionally, they never asked any of us two eyewitness hikers. We had to reach out to them in July / August 2013 even though our photos were in the media. OPS Musser and BRHS Frisby also had to reach out to the SAIT to be interviewed months later.
Regarding the (1) "SAIT-SAIR - we will never know" (Figure 10) and the (2) "Unaccounted for YH Fire and the GMHS Evidence" (Figure ??) and the (3) "Securing the scene?" (Figure 37) and (Figure 58 - Part 2 of 5) images and sections, please consider the select Yavapai County Sheriffs Office Deputy Report for Incident [Yarnell Hill Fire] 13-021744 link below excerpts below, dealing with all three (3) areas of concern and consternation. You will discover some amazing, yet unsurprising, things in that link below as you read through the entire document.
The fatalistic SAIT-SAIR rhetoric of "we will never know" and the damage done by advancing the defeatist and fatalistic claim that "we will never know" certain details about the GMHS tragedy makes it a self-fulfilling prophecy. SIX times! Yes - SIX TIMES - the SAIT unequivocally asserts "we will never know" - each time stating with more certainty than ever that "we will never know." The fatalistic rhetoric of the SAIT, a professional "Investigative Team," merely gives up as to why the entire GMHS that was on top of The Weavers safely ensconced in their Safety Zone and then hiked downhill through unburned chimneys and chutes and into a bowl to their deaths. Other than a few cursory mentions in the SAIT-SAIR of us, "Tex" Harold Eldon Gilligan (Sonny) and me, Joy A. Collura, the SAIT completely failed to include any of my numerous photos of the GMHS, the GMHS crew carriers parked in the unburned, Div A Eric Marsh, "Mystery Man" talking with Eric Marsh, the fire behavior, and much more, We also were up there on the peak of the Weaver Mountains, and we made it out safely without the benefit of radios or Air Attack or a supervisor.
The repeated "we will never know" assertion smacks of resignation, which is another way of saying giving up; and "resigned" is one of the identified Hazardous Attitudes in the IRPG, merely in a different tense ("Resigned – We can’t make a difference") on page xii. (emphasis added)
Providing the truth about the YH Fire and GMHS causal factors to the WF and FF world and in the media is essential for closing the "we will never know" gap and creating effective and necessary changes to reduce WF and FF deaths. Without knowing the causal factors, and thus the possible solutions, the world's readers and investigators are more likely to reject the threat of being forced to learn "incomplete lessons" as concluded by author and researcher Dianne Vaughan regarding the NASA Challenger Space Shuttle Disaster. Moreover, the process and mechanisms behind the "normalization of deviance" make gradual change difficult to detect until it’s too late. It seems that many in the younger WF/FF Community view the YH Fire as their figurative "gold standard" to examine other fires and fire experiences know nothing of the human factors of the Mann Gulch, South Canyon, Thirty Mile, Cramer, or Esperanza Fires, much less former wildland fire fatality investigator, Dr. Ted Putnam. And they seem to have drank the SAIT-SAIR kool-aid as well. Therefore, many of them are unknowingly headed on that same YH Fire trajectory, unless we change course and address the truths (and lies) about the YH Fire. We must do our best to effectively reduce the inevitable future WF and FF deaths.
Borrowing from Vaughan, 'Framing WF and FF safety in a fatalistic assertion of never knowing why as a solution-less problem may create a scenario where that is and will in the future, become true.' Vaughan, D. (2005) "System Effects: On Slippery Slopes, Repeating Negative Patterns, and Learning From Mistake?"; cited in "Organization at the Limit. Lessons from the Columbia Disaster." Eds. Starbuck, W.H. and Farjoun, M.
The well known and now "accepted" and endorsed practice of first establishing a "conclusion" and then finding the "facts" to fit their conclusion has shamefully and tragically been the norm all the way back to the Mann Gulch wildfire fatalities in 1949. It all sounds like a self-fulfilling prophecy to me. Could it be based on the fact that the SAIT and / or its sycophant minions altered, destroyed, fabricated, and /or removed a lot (read most) of the valuable evidence / records (e.g. cell phone records, videos, cell phone videos, AFUE records. etc.) and coerced and / or pressured employees to destroy them and /or not discuss the YH Fire and the GMHS debacle to ensure that "we will never know"?
In the YH Fire case, many, if not most, of the WFs and FFs and public hoping for complete lessons learned, instead rise to the level of the SAIT's expectations of "we will never know" and merely quit looking any further. What's the use of even trying to find out about anything except what is in the alleged "Factual" SAIT-SAIR because the experts on the SAIT have already told us six times that "we will never know." So then, they want you to just shut up and drink the Kool-Aid.
"The self-fulfilling prophecy inherent in such procedures hinders the investigative process by decreasing the chances of finding any answers, including surprising and counter-intuitive results." (emphasis added) (Mark Van Vugt, a Dutch organizational psychologist - "Self-interest as self-fulfilling prophecy" (2001)
Therefore, it should be clear, based on author Van Vugt's conclusion above, that the SAIT fully intended to "hinder the investigative process," especially the part about "finding any answers, including surprising and counter-intuitive results" as repeatedly revealed in this post and on this website as well as from your own intuition and permissible conclusions and inferences, based on your training and experiences and time-in-grade, bearing in mind that all inferences must be drawn quite cautiously.
This is a pretty good article on the positive aspects of the self-fulfilling prophecy concept. "The Impact of Self-Fulfilling Prophecies - Attitudes and Performance" (December 1, 2010) Dr. Fitch ( bdfitch@lasd.org )
( https://leb.fbi.gov/articles/featured-articles/attitudes-and performance-the-impact-of-self-fulfilling-prophecies )
Another link that must be cut and pasted to locate the document.
Further research from Nuberg, Judice, Virdin, and Carrillo (cited in Tauber, 1997, p. 14) define self-fulfilling prophecy in the following way; "The literature suggests that self-fulfilling prophecies are often mediated by expectancy-revealing perceiver behaviors; behaviors that suggest to a target how a perceiver feels ... communicated both nonverbally and verbally, either intentionally or not. Importantly, expectations influence such expressive behaviors, and these behaviors influence the action of others." (emphasis added)
Okay, I think I get it now - just because the SAIT tells us that "we will never know" - we are expected to dutifully, in lock-step, just give in and give up and concede that "we will never know"? Okay, I'll just drink the Kool-Aid and give up while watching this YouTube video! ( https://youtu.be/y51kYjVhm7g ) This is a good one that makes our point.
Here is an interesting public comment, supporting the "we will never know" quote from the PFD Wildland Battalion Chief Willis, the direct supervisor of the GMHS on June 30, 2013. "I believe there were circumstances that occurred and decisions that were made that we do not have facts on [what] contributed to their deaths," Chief Willis told ABC News. "We will never know what they were thinking or their decision process." (emphasis added) ( https://abcnews.go.com/Blotter/deaths-granite-mountain-hotshots-exposes-fight-airtankers/story?id=20424310 )
On the contrary, I believe we absolutely do "have the facts on [what] contributed to their deaths." It was years of bad decisions with good outcomes, "the Rule of 99," and the normalization of deviance. In October 2013, at a SW Area HS YH Fire AAR, an experienced HS Supt. concluded during the reflective Integration Phase: "This is the final, fatal link in a long chain of bad decisions with good outcomes, we saw this coming for years," with as many as eight HS Supts. and /or Assistants stating that they had all tried peer pressure to alter their unsafe behavior, to no avail. And we do "know what they were thinking" and what "their decision process" was. They were thinking and discussing their options of whether to stay in their safety Zone or relocate elsewhere while watching the increasing fire behavior for almost an hour according to this WFSTAR poster titled: "52 Minutes - Blow-up to Burnover" at Figure 18. And "their decision process" was clearly intuitive and mission-biased, adversely influenced by a multitude of stressors and certainly faulty and fatal!
Furthermore, one of the SW Hot Shot Crew Supts. at the 2013 GMHS Memorial Service in Prescott, AZ, suggested to 'Honor the Fallen' collaborator, Curtis Heaton, that 'we as a Hot Shot community and as a wildland fire culture, needed to look deeply into the YH Fire GMHS tragedy human factors to determine why this occurred to lessen wildfire fatalities.' The 'Honor the Fallen' lapdog Heaton's response to this concerned HS Supt. was "we will never know."
Absolutely refusing to drink the Kool-Aid here on this "we will never know" feculence! Indeed, I think it is safe to say that possibly many of us ("we") know exactly "what they [GMHS] were thinking" and "their decision process." On the contrary, it was the YH Fire SAIT alleged "Investigators" that were lacking in that critical area of responsibility. The individual GMHS were obviously thinking different things at different times depending on their responsibilities and status or even location. GMHS Steed was probably thinking that it was a bad idea to leave their safe black, with many of the the others thinking the same thing - all based on their access to their "Discussing our options" discreet Crew Net radio conversation. The Rookies - the true heroes - were thinking that they should trust their Bosses to do the right thing. And DIVS A Marsh probably was thinking he wanted the GMHS to do exactly what he possibly told them to do - leave their Safety Zone and hike down into the unburned at the worst possible time. And unfortunately, due to the intense stress factor at that time, the GMHS "decision process" was simply to fall back on one of the hazardous actions that they were most familiar with - and that was to avoid letting any overhead know their intentions, their location, or what they were doing.
And what was the GMHS most familiar with? According to German psychologist, researcher, and author Dietrich Dorner, the GMHS fell right in line with his remarkable conclusions: “... the violations of safety rules were by no means exceptions committed for the first time. They had all been committed before – if not in this precise sequence – without consequences. They had become established habit in an established routine. The operators did things this way because it was the way they had always done them before.” (emphasis added) (1998)
Pissed off? Incredulous? Giving up or giving in? Stay the course. There is hope! All is not lost.
You've finally made it to the solution to all this nonsense! There is hope with the "Psychological Reactance Theory."
An article in Psychology Today states that "Most of us don’t like it when people tell us what to do. According to psychological reactance theory, we desire to have freedom of choice and therefore have a negative, aversive reaction (called “reactance”) to having some of their [own] options taken away by other people or by external forces. Reactance produces three main consequences. First, it makes you want the forbidden option more and/or makes it seem more attractive. Second, reactance may make you take steps to try to reclaim the lost option. Third, you may feel or act aggressively toward the person who has restricted your freedom ... . Consistent with reactance theory, research has shown that labels designed to warn consumers about potentially objectionable material in TV programs, films, video games, and music often have the opposite effect of making them more interested in the 'forbidden' media." (emphasis added and footnote omitted)
So then, step right up and join the negative, aversive reaction movement today and refuse to believe in or drink the "we will never know" Kool-Aid. ( https://www.psychologytoday.com/us/blog/get-psyched/201302/why-do-people-denyviolent-media-effects )
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How many of you were aware of this public DropBox gold mine of photos given to the SAIT? The images that I, Joy A. Collura, freely and transparently shared with the SAIT investigators ended up in their own special folder in the SAIT documentation. And only minimal photos including the GMHS hiking up the two-track road that morning were the only one to make it into the SAIT-SAIR. That folder is still here:
(https://www.dropbox.com/sh/02ue6bnjp6nazkm/AAAQHmeW4AtE4acHagKGrrcSa/Photos%20and%20Video/Hiker%20Photos%20Videos/Reduced%20Photo%20Images?dl=0 ) This link also requires cut and paste to access the DropBox.
My photos show "where" fire behavior, vehicles, WFs and FFs, Air Attack, and other aircraft were on June 30, 2013.
"Impact Human Performance, Human Performance, Leadership, Organizational Performance, Safety Performance, and Situational Awareness" to businesses and other interested groups. What in the World Were They Thinking? Ron Ragain - The Rad Group - April 19, 2016 ( http://www.theradgroup.com/the-rad-group )
Go to Part II: Part 1 of 5 - Underneath every simple, obvious story about human error,’ there is a deeper, more c-B (yarnellhillfirerevelations.com)
If you right click and click "print" and save as PDF- 89 pages.
#Granite Mountain Hot Shots (GMHS) #TRUTH MATTERS #Lessons Learned # Yarnell Hill Fire #Serious Accident Investigation Team (SAIT) #Human Factors author #Sidney Dekker #Field Guide to Understanding 'Human Error #Newtonian epistemology #Albert Einstein # Sesame Street and Shrine Fuel / Fire Break Corridor area firing operation #liars create the 'illusion of truth. # Nazi Joseph Goebbels #Heraclitus #Spartan army #Schoeffler, Honda, Collura #National Weather Service meteorologist #Craig Harris, Sean Holstege and Bob Ortega #Forensic Weather #David Hume #"10 and 18" and LCES #Fire Orders #Williams 2002 #Swiss Cheese Model #Caples Prescribed (RX) Burn #Sensemaking #Dr. Ted Putnam #2011 International Association of Wildland Fire ( IAWF ) #Carrie Dennett #MegaBurn #Ron Ragain #Dietrich Dorner #52 Minutes - Blow-up to Burnover #Chief Willis #Vaughan #Dianne Vaughan #Tex" Harold Eldon Gilligan (Sonny) #Joy A. Collura #Yavapai County Sheriffs Office Deputy #Former Yarnell Fire Chief Pete Anderson #SAIT "Investigator" Kurth #FACEBOOK #18 U.S.C. #Cally Carswell #Rick Swan #Arizona State Forestry Division (hashtag)
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Update October 5th, 2022, 12:58am- Fred J. Schoeffler has my full permission to use any and all content from "Part 1 of 5 - Underneath every simple, obvious story about ‘human error,’ there is a deeper, more complex story - a story about the system in which people work. Will these formerly unrevealed public records change the account of what occurred on June 30, 2013? " on his new "Project 10 and 18 United" / "Project 10 and 18 International" blog he is creating.- Joy A. Collura
