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What's up with Incident Reviews?

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What's up with Incident Reviews? Winter 2014 ▲ Vol. 3 Issue 4 ▲ Produced and distributed quarterly by the Wildland Fire Lessons Learned Center What’s Up with Incident Reviews? By Travis Dotson Reviews. Reports. Investigations. Chances are good that you have heard all three of hese days it seems there are incident reviews for everything—from a decision to not cut a these terms used interchangeably. But, are tree, to a minor vehicle accident, to the full-on fatality report. There are definitely more they interchangeable? At the Wildland Fire reviews and more types of reviews out there than ever before. Lessons Learned Center, we use the term T In the eyes of the Wildland Fire Lessons Learned Center, that’s a good thing—it’s more material to “reviews” to cover all of them. They are all housed in our Incident Review Database: use for learning! However, with all of these different types of reviews, it sometimes gets [http://www.wildfirelessons.net/irdb]. confusing—especially when they all look so different, even the same type of report. Regardless of the specific type or format of For instance, the Serious Accident Investigation (SAI) and Facilitated Learning Analysis (FLA) can look the document, we place them all here drastically different. In some cases, we have multiple reports on the same incident (Yarnell). What under the generic umbrella of “reviews.” gives? Let’s see if we can shed some light on this issue. Let’s start with our most -used guidance. The 2014 Red Book (Interagency Standards for Fire and Aviation Operations) says there are 10 different types of “Reviews”. [See table at top of Page 3.] Please Because so many reports officially fall under this category, let’s focus on the “Lessons Learned Review”. The Red Book says: [The yellow highlight—throughout this article—is mine.] Provide Us with Your The purpose of a LLR is to focus on the near miss events or conditions in order to prevent potential serious Input incidents in the future. In order to continue to learn from our near misses and our successes it is imperative to conduct a LLR in an open, non-punitive manner. LLRs are intended to provide educational opportunities that foster open and honest dialog and assist the wildland fire community in sharing lessons learned information. LLRs provide an outside perspective with appropriate technical experts assisting involved personnel in identifying conditions that led to the unexpected outcome and sharing findings and recommendations. https://d Fairly straightforward, right? If something bad almost happens (or one of those rare occasions in which we bit.ly/2mcfeed try to learn from something going right), be nice to those involved and help the rest of us learn from their back story. Pay attention to that last Red Book sentence (above). It’s a big deal in the incident review world. [Continued on Page 3] In this Issue Page 2 Page 5 How do we really learn from an event? Two entrapment reports/learning approaches. Which works for you? Page 7 Page 8 RLS: Share your lessons rapidly with others IHC Superintendent reveals his insights on reviews Difficult suggestions on what you should be leaving behind Page 11 1 Ground By Travis Dotson Fire Management Specialist Wildland Fire Lessons Learned Center Truths [email protected] Where is the Learning? first off, let’s get one the ones we focus on. The reports thing straight: I immediately gain new skills or OK, “Ground Truths” is behaviors from are the super the world according to Travis simple two-pager types with Dotson. That’s all. Just like some concrete, actionable lessons: incident reviews are the world Use a drill to roll hose according to that author or team. I Move away from flame have no power over anything other when your saw vapor locks than maybe what people talk about Practice making a “back- in line for chow. Some people like country litter” reading my rants. But, then again, people like watching monkeys at That stuff makes sense the zoo. So if you want to complain immediately. It sticks with me and to my supervisor about what I say I put it into practice when faced because it’s different from what with a similar situation. These are you think, go for it. But keep in mind, I’m not writing policy the type of reports I think we learn the most from. or even influencing it. I’m just a knuckle-dragger with no education who stumbled onto a keyboard. How much we learn from an incident (especially a high- profile fatality) is a different deal. That process involves Now, my thoughts on reports/reviews/investigations— questions, discussions, simulations, and most importantly: whatever you want to call them. I have one big beef with time—which requires patience. (See my previous “Ground reports, and it’s not even with reports themselves. It’s how Truths” rant on Patience.) much emphasis we put on them. So please don’t confuse learning from an event with just Learning from an event is not the same as writing OR writing OR reading a report. That’s not how it works. reading a report. That’s my only issue. Learning from an event is a very involved process. The report is just one part If you’re writing reports, focus on telling the story in detail. of that process. And, in some instances, it’s not even Include pictures, videos, quotes and firsthand accounts as necessary. often as possible. Remember, your report is a small (but important) PIECE of the process. I have learned a lot from the events surrounding July 6, 1994. And not one of When you read the things I learned is a reports, don’t expect result of just reading the lessons to be the report. Everything spoon-fed to you on I’ve learned has come paper. That’s not from discussion with where the learning is. people I know and Learning comes from respect, walking the the intentional actual ground, hearing interaction you from those who were engage in after the there, and participating reading. in the Staff Ride. The report is just context. Learn on, Tool Swingers. Now there are reports I think we learn instantly from, but they’re not 2 From the 2014 Red Book: [Continued from Page 1] Review Types and Requirements It highlights a difference in perspective that results Delegating or Type When Conducted in such different looking reports. The charge to Authorizing Official identify conditions (rather than “cause”) gets a lot Annually, or Local/State/Region/ Preparedness Review of folks riled-up. (More on that later . ) management discretion National After Action Review Management discretion N/A According to the Red Book, at a minimum, an LLR Geographic Area should do the following: Fire and Aviation Safety As fire activity dictates Coordinating Group Team Review • Identify facts of the event (sand tables may be helpful in the process) and develop a chronological Safety Assistance As fire activity dictates Local/State/Region/ narrative of the event. Team Visit National Aviation Safety Assistance As aviation activity State/Regional • Identify underlying reasons for success or Team Review dictates Aviation Manager or MACG unintended outcomes. Refer to NWCG Large Fire Cost Review Agency Director • Identify what individuals learned and what they Memorandum #003-2009 would do differently in the future. Individual Fire Review Management Discretion Local/State/Region/ • Identify any recommendations that would National prevent future similar occurrences. Lessons Learned Review Management Discretion Local/State/Region/ • Provide a final written report including the above National items to the pertinent agency administrator(s) Rapid Lesson Sharing Management Discretion N/A within two weeks of event occurrence unless otherwise negotiated. Names of involved personnel Escaped Prescribed Fire See Interagency Prescribed Fire Planning and should not be included in this report (reference Review Implementation Procedures Guide (PMS 484) them by position). Peeling Back More Layers Sounds great. But how often do we see LLRs? It seems like most of what we see is the FLA. Where do those fit in? More clarification from the mighty Red Book: FLAs are a type of Lessons Learned Review. That’s a bit confusing. So, let’s peel back one more layer. Check this out, again, from the Red Book: • A LLR should not be used in lieu of a Serious Accident Investigation (SAI) or Accident Investigation (AI) if the SAI/AI criteria have been met. • FS [Forest Service]- Facilitated Learning Analysis (FLA) may be used for incidents meeting the AI criteria. Again, a little confusing. To me, what it says is “No LLR” if it’s an “Accident” (see definition below)—unless you’re the U.S. Forest Service (who can use an FLA, which is “a type of LLR”). Are you tracking? I think I need a map. [Check out my map above right.] ‘AI’ and ‘SAI’—What are They? So now we can talk about the Accident Investigation (AI) and Serious Accident Investigation (SAI). First off, what are they? The good ole Red Book says: • Wildland Fire Accident An unplanned event or series of events that resulted in injury, occupational illness, or damage to or loss of equipment or property to a lesser degree than defined in “Serious Wildland Fire Accident”. • Serious Wildland Fire Accident An unplanned event or series of events that resulted in death, injury, occupational illness, or damage to or loss of equipment or property. For wildland fire operations, [Continued on Page 4] 3 [Continued from Page 3] Flashback on Serious Accident Reports a serious accident involves any of the following: 1937 . One or more fatalities; Blackwater Fire – 15 Firefighter Deaths “Regrettable as it is, it must be recognized that in man’s .
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