United States Department of Agriculture

Twisp River Fire Fatalities and Entrapments

Operational and Organizational Learning Report

Fall 2016 Contents About This Report ...... 3 Operational and Organizational Learning Report ...... 3 Introduction ...... 3 Part A: Operational Improvements ...... 4 Type 3: Operational complexities and pressures ...... 4 Type 3: Looking at the big picture ...... 5 Type 3: The “go to” person ...... 6 Type 3: Building your team as you go ...... 6 Building depth of qualifications and improving pre-season training ...... 7 Making sense of complex weather data ...... 8 The time wedge and building a safety margin ...... 8 Ingrained routines and the incentive to engage ...... 9 Structure protection ...... 10 Uncertainty: non-routine responses are necessary ...... 11 New tools coming to assess risk ...... 11 Part B: Organizational Considerations ...... 16 Policy, guidance, and leader’s intent ...... 16 Greater emphasis on fire-resilient landscapes and communities ...... 16 Intuitive benefits of communication and relationships ...... 17 Lessons from other high-risk professions ...... 19 Conclusion ...... 20 Safety Action Plan ...... 22 Operational (Field) Action Plan ...... 22 Wildland fire communications ...... 22 Provide fire responders with better intelligence information ...... 22 Scenario-based training ...... 23 First-year firefighter and driver training standards ...... 23 Experiential emergency driving training ...... 23 Develop ways to better support Type 3 Incident Commanders ...... 24 Organizational (Leadership) Action Plan ...... 24 Develop and incorporate pre-fire risk and danger zone assessment tools ...... 24 Detect and study patterns within the current system: Conduct a broad spectrum learning review 24 Conduct a national wildland fire safety cultural change initiative ...... 25 Develop the next level of long-term leader’s intent that provides increased margins of safety ...... 25 Twisp River Fire Fatalities and Entrapments Organizational Learning Report Page 1 of 28

Appendix ...... 26 Training and Qualifications ...... 26 Driver qualification ...... 26 Quality of pre-season training ...... 26 Emergency driving training opportunity ...... 27 No ethanol present before accident ...... 28

Twisp River Fire Fatalities and Entrapments Organizational Learning Report Page 2 of 28

About This Report The Learning Review approach has been used to explore the Twisp River fatality incident. Several products were created as a result of this study: a status report,1 expanded narrative, this operational and organizational learning product, a field-learning (overview) video,2 and others. This report highlights how leadership has been proactively addressing safety issues, specifically, how the Safety Engagement sessions and Life First dialogues have already begun to address many of the systemic weaknesses that have been identified up to this point during the Twisp River Learning Review process. Recommendations are provided that explore new terrain, such as new ways to learn, the need to map our current system of work, and the need to improve change-recognition, sensemaking, and communication. We have found that our employees seem to value videos as well as written reports. So we supplemented this operational and organizational learning product (written for the national leadership audience) with videos that use plain language to introduce the concepts described in the report. These vignettes are embedded throughout this document. Some section headings are hyperlinks that take readers to a video that introduces that section. Vignettes are also embedded within the body of the document at strategic locations. Twisp River Fire Fatalities and Entrapments Operational and Organizational Learning Report Introduction On August 19, 2015, the Twisp River Fire in the state of Washington tragically cost the lives of U.S. Department of Agriculture, Forest Service firefighters Rick Wheeler, Andrew Zajac, and Tom Zbyszewski. The fire also severely injured another Forest Service firefighter and resulted in the burnover and injury of three Washington Department of Natural Resources (DNR) firefighters. As we started reviewing this event, it became apparent that more lives could have been lost. The Forest Service (FS), Okanogan County Fire District 6, and Washington State Department of Natural Resources (DNR) responded to Twisp River in a combined effort to suppress the fire. All three of these partners operate in the wildland fire environment under different mission goals and mandates. The interagency nature of this fire allowed for a deeper understanding of the situational complexity inherent in joint operations. As a result, the Twisp River Learning Review is the first interagency Coordinated Response Protocol and Learning Review. The Twisp River accident was not an individual or system failure but the effect of complex conditions. The individuals who worked at Twisp River carried out actions based on their training, knowledge, and experience. The system operated on standard protocols based on organizational, public, and firefighter values. However, the Twisp River individuals were placed in a position where they had to navigate multiple conflicting goals, rules, expressed leaders’ intentions, and laws. This is

1 Go to http://www.wildfirelessons.net/HigherLogic/System/DownloadDocumentFile.ashx?DocumentFileKey=77159beb-18bd- bdbc-57ad-12fe11d38cd2&forceDialog=0 2 Go to https://youtu.be/1q1JlP11xbY Twisp River Fire Fatalities and Entrapments Organizational Learning Report Page 3 of 28 not a new or unique situation; it actually is highly representative of the complex nature of firefighting and is especially prevalent in the wildland-urban interface (WUI). The goal of this Learning Review was therefore to understand the complexities and situational factors that influenced decisions3 (click the link to view a vignette about decision making) and actions at Twisp River. Accident investigation in wildland fire responses historically focused on individuals as a way to recognize and control error. The local firefighting community was deeply concerned about the potential outcome of the investigative process. We made a concerted effort to help the community at Twisp River understand the value placed on learning from the event through the Learning Review process. The result of this hard work was that most of the community of fire responders opened up to the team and provided information willingly. We used the Learning Review method to understand and illuminate what happened at Twisp River. This started by building a narrative that included multiple perspectives. Conditions that influenced decisions and actions were identified and mapped. This allowed the team to recognize areas of systemic vulnerability. The narrative and map were then shared with three different focus groups: fire responders, line officers, and fire behavior specialists. In addition, more than 20 other subject- matter experts and academic specialists reviewed the same material. Each of these groups, experts, and specialists provided an outside review that helped make sense of what happened and identified what could be learned. This report presents results of this process and what the team learned. It has been broken into two parts. Part A deals with short-term/operational improvements: how we get better at fighting fire. Part B deals with longer-term/organizational and broad-scale issues such as overall land management strategies and cultural changes. To view a video that shows a broad overview of the Twisp River incident, please click on the following link: Twisp River Overview.4 Part A: Operational Improvements Type 3: Operational complexities and pressures5 A reoccurring topic during focus group sessions and interactions with specialists was the nature and complexity of rapidly emerging Type 3 incidents. These fires move quickly through the classifications from Type 5 to Type 3. Conditions such as fire behavior, a high threat to homes, a need for a large number of firefighting resources, or other complicating factors can trigger a transition to a Type 3 incident. The pressures in wildfire are perhaps nowhere more apparent than in a rapidly emerging Type 3 incident. The Type 3 Incident Commander (ICT3) is tasked with bridging the gap between initial attack and extended attack. According to findings from focus group efforts, many in the fire service

3 Go to https://youtu.be/VSX3Paq0HwU 4 Go to https://youtu.be/1q1JlP11xbY 5 Go to https://youtu.be/O5Vb46LkvLc

Twisp River Fire Fatalities and Entrapments Organizational Learning Report Page 4 of 28 consider this position to be the most complex and challenging position in wildland fire. The current system asks ICT3s to make order out of chaos and to organize for the long-term while giving up as little ground as possible when the situation is at its most dynamic, developing, and uncertain. Twisp River was a typical rapidly emerging Type 3 fire. The initial response was to engage in full suppression, which is consistent with established routine. Once on scene, fire responders adopted a rapid-response mode designed to anchor, flank, and pinch the fire. Had this been successful, we would have counted Twisp River as one of the 98 percent of fires that are caught before they become large. However, the conditions at Twisp River did not deliver the expected outcome. The presence of structures in the area led fire responders away from their initial strategy of anchor, flank, and pinch, and containment was thwarted by a wind shift. This all took place in an environment that requires people to determine what is safe while simultaneously trying to protect values at risk. This presents fire responders with a growing challenge. Structure protection further complicates any assessment of what is safe enough or aggressive enough. Under the current firefighting model, fire responders had to rapidly negotiate these conditions at the point of work. Several of the focus groups keyed in on this issue by asking questions about how fire responders assess conditions prior to changing plans or to extending actions beyond the initial plan of action. These questions centered on topics such as risk assessment, mission goals vs. fire responder identity, sense of purpose, desire to do a good job for the community, and sharing information. Type 3: Looking at the big picture An underlying principle in wildland fire operations is that wildfires are often emergency situations. Keeping fires as small as possible decreases the risk and exposure to fire responders and the public. Immediate action requires fire managers to specify tactics for fire engagement; clarify jurisdictional decision-making roles; establish communications; and make safety plans—all simultaneously in a time-compressed environment. As a result, during initial attack operations, available time and attention to developing a plan of operations is in competition with developing and taking tactical implementation steps. This normal work practice surprised several experts who were asked to read the Twisp River narrative and provide outside perspective. After explaining to them that this process was common on rapidly emerging Type 3 incidents, they questioned whether other organizations that manage similar risks, such as the military, have a tactical plan in place and an established organizational structure like the Incident Command System (ICS) before engaging in a potentially dangerous operation. Our agencies need to examine improving this “normal” process. This could involve recognizing trade-offs with time and efficiency that may be necessary, emphasizing adaptability and avoiding outcomes that make it difficult to recognize and respond to change—a term the Learning Review team referred to as “brittleness” in our operations. In the wake of the Twisp River incident, it seems prudent to take a step back and reflect on our current system of work6 (click the link to view a vignette about the current system of work). The following questions emerged from discussions with subject-matter experts:

6 Go to https://youtu.be/TNy1vgsPMB4 Twisp River Fire Fatalities and Entrapments Organizational Learning Report Page 5 of 28  Who is looking at the big picture? Not only that, but who knows what to do about what they're seeing and when to do it, definitively?  How do people who arrive with different perspectives best compare information? Then, what do they do about that information in a way that will do any good?  How do we get to a point where we know it’s important to retreat and do that definitively as opposed to continuing to engage? How do we help people learn how and when to disengage when they are otherwise rewarded over the course of a career for running in when others are running away? This suggests the need for us to include an additional position on our emerging incidents—an individual who is trained and empowered to support the ICT3 on “big picture” and important safety considerations. There is also an opportunity to evaluate how leadership can create an environment where employees can be successful. This will require leadership to develop new ways to build a “safety margin” into operations prior to any engagement or commitment of resources. There are a number of ways to do this.

Type 3: The “go to” person7 In general, ICT3s are responsible to manage all aspects of an emerging Type 3 Fire. These individuals must meet the following requirements:  A qualified ICT4 and

o Either a Task Force Leader o Or being qualified as a Strike Team Leader and being qualified in any two Single Resource Boss positions (one of the Single Resource Boss positions must either be Crew Boss or Engine Boss). Qualified ICT3s become the “go to” person who is expected to engage in several different tasks that have not been required up to this point in his or her career. The prerequisites to becoming an ICT3 are heavily weighted toward tactical and operational fire response functions. However, once the transition to ICT3 is made, responsibilities expand to requiring a more comprehensive knowledge of systems and processes of which they only needed a cursory knowledge as an ICT4, including shift tickets, incident finance rules, 2 to 1 work/rest ratio justification letters, delegation of authority letters, emergency medical technician control issues, and logistical challenges inherent in a much larger workforce than they may typically handle. This is all happening against a backdrop of incidents that have escaped initial attack, meaning the ICT3 is also confronted with increased fire behavior, often in highly complex8 (click the link to view a vignette about adaptive capacity) fire environments involving homes.

Type 3: Building your team as you go9 In some instances, ICT3s travel with a team of trained specialists who help carry the load of the incident response. In other situations, ICT3s are expected to build their team from the existing resources on hand. In this latter scenario, the ICT3 is responsible for operations, air operations,

7 Go to https://youtu.be/pgK9dCiQ2Rw 8 Go to https://youtu.be/UjWIQndY73I 9 Go to https://youtu.be/UAfF7q0BBY4 Twisp River Fire Fatalities and Entrapments Organizational Learning Report Page 6 of 28 planning, finance (including personnel time, procurement, and contracting), logistics, safety, human resources, public information, and other duties until he or she designates someone else to take on any of these roles. This system is set up so that as the fire increases in complexity and begins to overwhelm the ICT3, his or her only recourse is to order up supervisory positions and/or to rob supervisory personnel from the incident’s existing resources in order to attempt to “stay ahead of the power curve.” The Incident Commanders10 (click the link to view a vignette on unified command) on the Twisp River Fire found themselves in a position where they had to build their team as they went, which resulted in less experienced people being asked to take on leadership roles during an extremely complex event. Engines were turned over to Assistant Captains; squads were led by less experienced Squad Bosses. The current wildfire system does not always have the depth in qualifications to create a Type 3 team without stripping leadership from individual response units. If leadership is stripped off of a unit, a decision has to be made about how to use the remaining less experienced team members. This adds complexity to the IC’s role. Building depth of qualifications and improving pre-season training Building the team as you go by reassigning supervisory personnel at Twisp River points to a need for improved depth of qualifications and training. It also reinforces the need to stress that we do not separate leadership from modules or crews unless another member of the crew is fully qualified. While this may be a common practice in some situations during initial attack, the fast changing conditions with today’s fire behavior reveal the need to ensure that we do not separate leadership from crews. Employees have the full authority to decline assignments; however, this is an unfair burden to place on fire personnel, especially in rapidly changing fire conditions. The person serving as captain of the burned-over engine had been called away to provide supervisory expertise elsewhere on the rapidly-emerging fire. This left the next-most experienced firefighter as the engine driver during the emergency egress operations. The driver had taken the classroom courses needed for engine operation and was in the process of completing a Region- specific supplemental driving requirement of four hours of supervised driving under “actual conditions” before taking the final driving test (see Appendix). The surviving member of the Forest Service crew stated that he believes the basic fire training he received as a first-year firefighter was inadequate. The current minimum requirements to obtain a red card include completion of three online courses and a one-day field exercise. These requirements may not be enough, especially for employees who work in other disciplines and may not have as many opportunities for on-the-job training (see Appendix). The engine involved in the Twisp River incident was disabled when it ran off Woods Canyon Road. This brings to light a lack of vehicle-egress training. This type of training is common in other high- risk professions involving specialized vehicles. This could give firefighters an extra tool in life- threatening situations (see Appendix).

10 Go to https://youtu.be/iPWBKj3YYi4 Twisp River Fire Fatalities and Entrapments Organizational Learning Report Page 7 of 28 Making sense of complex weather data11 Weather forecasts are an ever-present product during fire season. They are talked about in every shift briefing and are inextricably linked to fire-behavior forecasts. The importance of needing to know the weather forecast is outlined in the first Standard Firefighting Order: “Keep informed on fire weather conditions and forecasts.” The National Wildland Coordinating Group has even created a class dedicated to observing and understanding weather. How then, if weather information and forecasts are so prevalent within the wildland fire community, do weather-related events still have so much influence over fatality incidents? In order to understand weather and fire behavior interactions on emerging fires, we are asking fire responders to interpret the raw data, which they are not trained to do. “It is all about processing that info, recognizing what it is, and applying it to the fire they are on,” suggested one fire behavior specialist. The specific relationships between weather and fire behavior are not well covered in the general training. A thorough understanding of this relationship is therefore generally only held by experts like fire-behavior researchers, fire-behavior analysts (FBANs), long-term analysts (LTANs), and fuels specialists. Are these forecasts providing the users what they need? Probably not, according to our fire- behavior specialist focus group participants. Fire responders are often operating as efficiently as possible, so that when a weather event occurs, safety margins are not great enough to absorb weather variability. “We can no longer just offer raw data, leaving the user to pick out what is most important,” noted one FBAN focus group participant. Context must be provided. We need to investigate emerging technology on the fireline; produce tools that interpret the raw data; and communicate what it means in a simple, flexible, easily understood manner that can be produced quickly. Further work also needs to be done on how fire responders make use of signals. Does our current system generate too many false positives?12 Could we do a better job of separating out the noise from the signals we want fire responders to especially notice? Further exploration of these questions may yield systemic improvements, which may lead to accident prevention. The time wedge and building a safety margin How to manage the time wedge is a skill taught in many of our firefighting classes. It’s based on the principle that keeping fires as small as possible reduces risk to firefighters and the public. The time wedge is sometimes perceived to be a one-way slide where the more time you spend gathering intelligence and making sense of the situation, the smaller the range of options available. The concept is reinforced each time we watch a fire progress towards a ridge or housing development while the physical space for taking action decreases. The time wedge is ingrained in our fireline training courses. Seemingly unrecognized in these courses is the considerable pressure to make decisions early without a robust situational picture or

11 Go to https://youtu.be/KhzpD_0MiVs 12 It is also important to focus on relationships and open dialogue. Fire responders and forecasters need to build relationships so that they can understand each other’s needs. Fire personnel should take the time to invite forecasters to speak at a monthly meeting or training. Forecasters should visit the fireline to see how their forecasts are being utilized. There also needs to be open dialogue between the two groups to ensure that the products being put out and the information being collected is adequate. Twisp River Fire Fatalities and Entrapments Organizational Learning Report Page 8 of 28

deliberation. Each fire has unique characteristics and conditions. Key pieces of information, such as a forecasted wind shift or a new resource arriving on the fire, can easily be overlooked when routine responses are enacted. In contrast, the concept of “safety margin” is used in aviation as a way to reflect on their complex operational environment. It focuses on the environmental, organizational, and personal conditions that influence decisions and actions. Unlike the time wedge, margin does not imply a linear, one- way progression towards an ever-decreasing decision space; rather it describes the collective influence of these conditions, which either increase or decrease the margin available. Margin operationalizes risk by making probability and severity topics that can be easily discussed. It is designed to help users describe the potential for harm before an accident occurs, based on reflection rather than a predetermined assumption that decision space is always decreasing. In aviation operations, decisions to maintain a wider safety margin are positively reinforced, and decisions to disengage or regroup when margin is low are often rewarded. As with the time wedge, margin is just a model and therefore is not a perfect representation of reality. The benefit of this concept is that it was designed in recognition that the world is complex and dynamic, not linear and unidirectional. We do face time pressures in the field; the fire will continue to advance across the landscape towards a management action-point or structures, but it is certainly not a given that our decision space is in constant decline. Margin provides a way to align our view of decision-making with the recognition that our operational environment is complex and dynamic. It is important to remember this complex system is comprised of all the land management agencies, state agencies, local responders, communities (especially those at risk), politicians, media, the public, and others. The pressures that these actors have on the decisions and actions of firefighting personnel may be influencing them to unconsciously narrow the options that they consider, inherently predisposing them towards unnecessary exposure. Should we be placing the burden of conducting a risk analysis at the scene of a fire on the people who are the most deeply influenced by the “can-do” culture and perhaps the most predisposed to take on risk? Or should we provide better organizational risk-identification products that can help take the burden off responders in the time constraint of an emerging incident? Ingrained routines and the incentive to engage The Learning Review team observed that unnecessary risk and exposure occurs within the wildland firefighting community when an inherent predisposition towards action results in routinized responses under dynamic conditions. When the outcome of this predisposition toward action is positive, it reinforces our tendency to act aggressively. Only after an adverse event like Twisp River do we organizationally question how aggressive initial attack is conducted. The response to this questioning is usually an admonishment of fire responders to increase their deliberative thinking while evaluating risk. In order to better understand how we behave with regard to risk-taking, we need to examine how risk may be unintentionally incentivized in the current wildland fire system. In our current fire culture, the “good” employee is the one who goes to great lengths to be productive. Training from the very first day teaches that fire is demanding and difficult work. Fire responders must give up personal comforts and work in hot, dirty, challenging conditions for long hours. Physical challenges Twisp River Fire Fatalities and Entrapments Organizational Learning Report Page 9 of 28

and depriving oneself of creature comforts become badges of honor. Standards for determining which crew is “better” hinge on comparing who has worked more overtime hours; can dig the most line; has endured more challenging fires and assignments; hikes the fastest or longest; or carried the most weight up the hill. This competition extends to individual responders. Perhaps an employee who is willing to take a risk that others aren’t (carrying the chainsaw all day; digging that last foot of line at the end of a long shift; or saving a structure just moments before the fire arrives) will be considered for a promotion next season or get that permanent position. We tend to respect crews and individuals who are strong, tough, and are willing to take on challenging assignments or as we have described it in the past, a “can-do” crew. Ingrained routines, such as the use of run cards to dispatch resources, may make it easier for those involved to take action. Run cards provide dispatchers with a pre-planned initial attack response to smoke reports. A run card is used in this way: when smoke is reported to a dispatch center, the reported location of the smoke is used to find the designated run card. This run card has a range of response levels listed. The response level is dependent on the weather and fuel conditions for that day. Response levels can be minimal—for example, a single engine—or a heavy response—for example, one helicopter, three engines, and a Type 2 Initial Attack crew. Run cards are not objective-based; they are response-based, given a level of fire danger. They do not consider the potential success of that dispatch in the context of fire-danger level or values at risk. Sometimes the run-card system results in more resources being dispatched, requiring additional needs for overhead personnel for oversight. Many times the resources that show up engage the fire with the mindset that “we are already here; we might-as-well do something,” with only secondary consideration of fire behavior, location, or resource benefit. Fire personnel have stated that they often feel the urge to engage upon arrival. Each incident can provide an opportunity for a training assignment or for personnel to gain on-the-ground experience. Some of the pressure to act may come from standards such as the Forest Service Fire Program Management (FS-FPM) standards that were implemented in October 2013. These provide a set of qualifications for each primary and secondary fire position within the Forest Service that must be met as a condition of hire. This means that without having the required qualifications, one cannot advance in his or her career. Training assignments can be few and far between, especially for incident commander assignments. This may put a lot of pressure on individuals to engage in suppression activities that they might otherwise refuse. Structure protection At Twisp River, the routine response and desire to perform were further exacerbated by the desire to save structures adjacent to the fire. Fire in the wildland-urban interface adds challenges to routine operations13 (click the link to view a vignette about the complexity of fires in the WUI) as neighbors, friends, and communities are perceived to be in peril. Responders intuitively react to messy—often conflicting—guidance in high-tempo and often high-risk situations. In these situations, values become intertwined with laws that govern local and state responses to fire. The review of the fire showed that none of the “control lines” fire responders dug held at Twisp River. In hindsight, we can now say that they exposed themselves to extreme risk completing a task

13 Go to https://youtu.be/fqasQkFfJf4 Twisp River Fire Fatalities and Entrapments Organizational Learning Report Page 10 of 28

that had no effect. Can we assess fires in a way that allows us to identify high-risk/low probability of success situations before we decide how to commit resources? Current research and other high-risk operations (structure fire, aviation, and the military) the team studied indicate that the answer to this question is possibly “yes.” Uncertainty: non-routine responses are necessary Another concern both field subject-matter experts and academic experts identified involves the dynamic, complex environment in which our fire operators work, particularly on rapidly emerging Type 3 fire events. Environmental conditions are constantly changing. Yet fire managers tend to engage fires using routine strategies and tactics. Many of these strategies are the same strategies used during the fires of 1910. Significant environmental changes, values at risk, and probability of success should influence the way fire managers engage the fire. They should have a range of tactical and engagement options that mirror dynamic environmental conditions, values at risk, agency missions, and ecological needs. These changes in our engagement strategies could inspire innovative new tactical methods and ways of engaging fire that reduces risk.

New tools coming to assess risk14 For those who have the best working knowledge about how to engage fires (the fire operators), it is inherently difficult, in isolation, to also identify which risks are acceptable versus unacceptable.15 How then should leadership make effective decisions about risk? Emerging research suggests that one possible solution lies in relationships and iterative dialogue coupled with organizational management of risk prior to the start of fire operations. Line officers or agency administrators often provide the big-picture view and may hold a more conservative approach toward taking specific types of risk.16 These leaders may be able to use humble inquiry17with their field operators by asking genuine questions about tactics and conditions to examine the types of risk that may be acceptable. The difference in risk perception between the agency leader and the fire operator may be small, but the interactions that result from sharing these differences may lead to major gains in reducing the acceptance of unnecessary risks. This type of interaction has been shown in other high-risk work environments to provide perspectives that would otherwise not be available. Forest Service researchers led by Matt Jolly (Rocky Mountain Research Station Research Ecologist) responded to requests for analytical pre-season geographically-based tools that could be used to help understand where accidents such as Twisp River are likely to occur. They are working closely with staff in areas such as the Lolo National Forest in Montana to develop three related products. One of the products is intended to help inform fire staff (e.g., duty officers) of the appropriate level of engagement on wildfires in their jurisdiction. The product is visual and is intended to be clear and simple to understand. If a new fire start is identified in an area with extreme fire behavior potential, there is an expectation of higher levels of leadership engagement, recognition of extreme caution,

14 Go to https://youtu.be/zW405rgpGJ8 15 Adams, J, 1995. Risk. Rutledge, London. 16 Adams, J, 1995. Risk. Rutledge, London. 17 Schein, E.H. 2013. Humble Inquiry: The gentle art of asking instead of telling. Berrett-Koehler Pub, Inc. Twisp River Fire Fatalities and Entrapments Organizational Learning Report Page 11 of 28

and direct engagement with the fire only under exceptional circumstances where appropriate fireline leadership is in place. The second product is a matrix (not pictured here) that identifies a series of questions designed to facilitate a discussion between the duty officer and the field ICs regarding environmental hazards. There is an expectation that these people will talk about whether the highest (red) category of hazard precludes engagement. This matrix recognizes the need to maintain decision-making authority at the duty officer level and is intended to structure and foster discussion, not to prohibit any specific action. Unique local perspectives and mitigation potential for each area should be the focus of the conversations. There is no one-size-fits-all matrix, as there is no one-size-fits-all approach to wildland fire. The third product deals with the wildland fire environment as a complex interaction between fuels, weather, and topography; the combination of these factors dictates how fires behave. Of these factors, weather is the most highly variable and has the most immediate impact on fire behavior. Firefighters are expected to “Keep informed on fire weather conditions and forecasts” (Standard Fire Order #1) and “Base all actions on current and expected behavior of the fire” (Standard Fire Order #3), but few tools exist to inform firefighters of expected fire weather and subsequent fire behavior conditions for a given point on the landscape. Long-standing tools such as the US National Fire Danger Rating System (NFDRS) can provide key information and support risk-informed decision- making but only if a clear linkage between fire-danger indices and potential fire behavior can be established. All three of these tools can be used to build positive relationships with communities and individual landowners in the wildland-urban interface and could foster greater understanding about what structure owners expect from their funded fire programs. Within these relationships, the agency fire managers can discuss openly what they can and cannot provide during a fire event. Setting boundaries about unacceptable risk before fire season begins regarding unacceptable risk may take some of the pressure off of the front line operators when they decide between suppression options. The NFDRS supports operational preparedness and wildland fire response decisions throughout the country. In addition to real-time assessments, it also currently provides operational forecasts for the next day through a partnership with the National Weather Service. This system was developed by the Forest Service in late 1970s and has remained essentially unchanged since its inception. Because the system was developed well before the prolific availability of both computers and mobile devices, some of its limitations severely impair its use as an operational wildland fire response tool.

Twisp River Fire Fatalities and Entrapments Organizational Learning Report Page 12 of 28

“Observation Time”

Figure 1: Hourly wind speed measured at North Cascades Smokejumper Base (NCSB) on 19 Aug 2015. The vertical line shows the typical ‘observation time’ for fire weather.

Responders need localized fire weather information to make well-informed, risk-based decisions. NFDRS is “weather-station-centric” and is currently only applied at Remote Automated Weather Stations (RAWS) that may be miles away from a specific fire. These weather stations report fire danger conditions that are meant to represent the “average worst case” conditions, yet they use daily observations and forecasts that are usually taken at 1300 hours Local Standard Time. Historically, mid-day observations were needed to ensure that manual weather observations could be collected early enough to allow the National Weather Service to produce the fire danger forecast for the following day and issue those forecasts before the end of the current duty day. However, RAWS observations and next-day forecasts are now completely automated and updated each hour via satellite telemetry. The use of “1300 observations” is an antiquated legacy that does not provide the best data to firefighters making decisions during peak burning periods that typically happen later in the day (see Figure 1). Another serious limitation of our current fire danger rating system is that it is not easily accessible to initial responders. Recent advances in both Web-based mapping and mobile computing provide new methods for conveying information. Estimates indicate that 95 percent of 18- to 34-year-olds have cell phones, and they use those devices as their primary means to access the Internet.18 Our current infrastructure for delivering fire danger information should keep pace with the rapid transition from desktop computers to mobile devices. Recent technological advances in computing and mobile mapping have the potential to address these deficiencies in our fire-danger rating systems. They disseminate data in formats that are easily

18 Pew Research Center’s Internet and American Life Project Surveys. Twisp River Fire Fatalities and Entrapments Organizational Learning Report Page 13 of 28 communicated and understood by firefighting decision-makers at nearly any spatial scale, from local initial attack to regional- and national-level coordination. Since 2006, work has been underway by the developers of the Wildland Fire Assessment System (WFAS) to provide near real-time mapping for fire danger and potential fire-behavior conditions continuously across the United States. This real-time mapping produces daily forecast maps of Energy Release Component (ERC) and Burning Index (BI). Based on the clear relationship between ERC/BI percentiles and potential fire behavior (see Figure 2), a categorical map of Severe Fire Weather Potential can be constructed (see Figure 3). The example map from the Twisp River Fire for August 19, 2015 shows that if this tool had been available to wildland firefighters and fire leadership before they responded to the new fire ignition, they could have seen the area was expected to experience severe fire weather and behavior for that burning period. A prototype, mobile-enabled version of this system is currently running operationally and is being refined during the 2016 fire season.19 This resource has tremendous power to communicate day-to- day and place-to-place varying fire weather conditions and to ensure that wildland firefighting tactics are consistent with the intent of the Standard Firefighting Orders. If the presentation of this information is kept simple and easily accessible, it could become a tool to inform the level of engagement on new incidents during initial attack as well as extended-attack fires.

Figure 2: Relationships between Energy Release Component (ERC) and Burning Index (BI) percentiles and observed fire behavior reported on active large fires in the ICS-209. There is a strong relationship between ERC, BI, and potential fire behavior across the Okanagan-Wenatchee NF and surrounding areas. The Twisp River Fire fatalities occurred on a day where extreme and erratic fire behavior would have been predicted if this approach had been implemented operationally.

19 Go to the WFAS - Severe Fire Weather Potential Mapping System Web site at http://m.wfas.net Twisp River Fire Fatalities and Entrapments Organizational Learning Report Page 14 of 28 Figure 3: Example of an operational Severe Fire Weather Potential mapping system that can be used to inform risk-based wildland firefighting decisions.

Twisp River Fire Fatalities and Entrapments Organizational Learning Report Page 15 of 28 Part B: Organizational Considerations Part A of this report deals with improvements to the current system as an intermediate step toward the greater issue at hand: identifying and making changes that promote systemic improvements for fire-responder safety. This section examines overall wildfire strategy and environment.

Policy, guidance, and leader’s intent20 Policy, strategy, legality, and intent around wildland fire is complex. It is important to clearly understand the differences in perception about fire as a natural process and the fact that unwanted fires must be controlled. The differences in the role of the Forest Service as compared to state and local agencies21 (click the link to view a vignette about interagency collaboration) center on the concept of managing fire versus full suppression. Focus group discussions point to the link between differences in agency mission, policy, intent, and other legal and political underpinnings. However, it is also clear that the perspectives vary among employees of each respective agency. Both the Forest Service and DNR are agencies whose mission, structure, training and equipment are designed to respond to wildland fires, not wildfires that now nearly always occur in environments where homes are threatened. Fire policy is fairly consistent with regard to its stated primary goal of “fire-responder safety.” The situation becomes more complex when we ask for aggressive firefighting to be balanced with safe operations.22 Line firefighting personnel are expected to resolve this tension. State and federal guidance mandates that fire responders engage in risk management as a way to approach the goals of safety and aggressive attack. However, perceptions of safety are influenced by operational experiences where aggression was successful; each success reduces a field operator’s sense of accident probability or severity.23 We do act in deliberate ways in wildland fire. No agency ascribes to “at-all-cost” actions. Is it possible to consider deliberate action (thought-out and evaluated) to be a form of “full suppression”? In most cases that is what our personnel do—so would it be in our best interest to write our guidance to reflect this reality—to shift our language so that our intent is clear for all the stakeholders involved in the system of wildland fire? Greater emphasis on fire-resilient landscapes and communities The current system relies largely on aggressive fire suppression, yet the more we suppress, the more we have to suppress. The negative re-enforcement loop of fire suppression requiring in turn more fire suppression has contributed to an increasingly complex and hazardous environment and represents a transfer of risk into the future. As a result, some believe we should consider adjusting our current fire-suppression model. The impact of severe megafires on landscapes, people, habitat, and communities is brutal and undeniable. Agencies are committed to protecting the public and carrying out their missions and are doing so in the face of ever-more complex and hazardous

20 Go to https://youtu.be/SGo2opT_mGg 21 Go to https://youtu.be/wp6kV3M6tvA 22 The National Cohesive Strategy states, “Safe aggressive Initial Attack is often the best suppression strategy to keep unwanted wildfires small and costs down.” 23 Adams, J, 1995. Risk. Rutledge, London. Twisp River Fire Fatalities and Entrapments Organizational Learning Report Page 16 of 28 conditions. We must explore ways to reconcile these perspectives and put greater emphasis on fire resilience. Fire responders are being exposed to extremely dangerous situations such as complex fuel conditions, climatic changes, and wildland-urban interface challenges. As they pursue multiple objectives, there is increased exposure to hazards. Twisp River is one example of how these increased risks resulted in fatalities. Unless we improve the way we fight fire, the lethality demonstrated here may continue to increase in probability. Fully suppressing fires under more difficult conditions requires increasing the number of fire responders to meet response needs in the expanding wildland-urban interface. Increasing the number of fire responders and resources will continue as agencies attempt to meet the demands of intensifying wildfire seasons although often these requests go unmet as the fiscal priority and sustainability of the investment is questioned. Ultimately, taxpayers can only bear the support of a certain number of fire responders and equipment. This reinforcing feedback loop of fire suppression is fraught with complex interactions. While some land management agencies manage and support activities to build fire-resilient landscapes, other partners lack laws, policy, and public support. Many people and communities who make their homes and livelihoods in inherently fire-prone areas have not committed to actions that would protect their values when a wildfire inevitably comes. We must work toward educating communities and taking action to develop more fire-resistant landscapes. One of the important, long-standing relationships that Twisp River has called into question is that of the fire response agency and the private landowner. Many questions after the tragedy at Twisp River revolve around what private owners expect in terms of structure protection. What should they expect? What can be reasonably provided, and who is best able to provide it? Although our fire managers are ingrained with the order to “fight fire aggressively, having provided for safety first,” we still need to improve our understanding about the need to protect structures as compared to the risk of human life. Building positive relationships with communities and individual landowners in the wildland-urban interface can foster greater understanding about homeowners’ expectations from their funded fire programs. Agency fire managers can discuss what they can and cannot provide during a fire event, noting areas of concern to firefighters. Establishing how fires will be engaged throughout the season will help landowners make informed decisions about how best to protect their assets and how to access their property. Before fire season begins, setting boundaries about which risks are acceptable for fire managers may take some of the pressure off later when making crucial decisions about when and which structures can be protected. Intuitive benefits of communication and relationships During the Twisp River Learning Review process, a focus group comprised of line officers was brought together to provide a leadership perspective about the incident. There was unanimous agreement that communication and relationships are the critical ingredients that help create a high-functioning team on a fire incident. Improvements could be made by increasing communication, building relationships, and helping fire responders make appropriate risk-based decisions.

Twisp River Fire Fatalities and Entrapments Organizational Learning Report Page 17 of 28 Figure 4: Risk-based System of Work in Relationships.

These skills24 (click the link to view a vignette on the importance of these skills) were also identified as pertaining directly to safety (see Figure 4). Communication and relationships allow for critical, safety-oriented information to be passed more easily from individual to individual and crew to crew. The lack of these skills often ensures that individual units remain isolated. When units are isolated, the complexity of an incident falls upon each unit, which can become overwhelmingly dangerous in a complex situation like Twisp River. The Line Officer focus group spent a few minutes trying to identify where and how they, as individuals, had gained their communication and interpersonal skills. Very few of the individuals cited agency training as a source although several individuals did identify some of the newer high- level leadership courses, specifically the Middle Leader course, which are beginning to teach some of these skills. If these skills are critically important for all fire responders, could—and should—the agencies invest in training and practice of these skills? And if so, when should these skills be taught—early or later in employees’ careers? To respond to the truly unexpected events, we must rely on others who are a part of the response. Adapting to rapidly changing conditions and events requires the ability to rapidly make sense of often weak and nuanced signals. Increasing our chances of acknowledging and taking appropriate action in response to these signals requires meaningful interaction among units on the incident. In the Twisp River Fire, there were positive examples of units relating to one another, such as when the point of contact (POC) for the left side handed off air resources to the POC for the right side because of a perceived shift in fire activity and priorities or at the meeting between the FD6 IC and the Forest Service ICT3 where they agreed on a tactical plan for structure protection. If communication and interpersonal skills are important, we should emphasize them in training. Focus groups noted the fire community’s inadequate emphasis on relationships. Training in the

24 Go to https://youtu.be/sG7nyn_Ad9s

Twisp River Fire Fatalities and Entrapments Organizational Learning Report Page 18 of 28 skills necessary for effective relationship-building is not available to incoming field-level operators, and very little is offered until much further along in one’s career. Lessons from other high-risk professions In most cases, people who fight wildland fires will not be killed or injured—the system is comparatively safe. However, the fire environment is demonstrating behaviors that have been unseen in the past. Fires like the ones in Washington last year tapped out resources from around the nation; fire responders were called in from around the world to help combat them. This change is important to note. When the system delivers the expected, then routine responses will be enough to meet the challenges. But when the system changes and begins to deliver the unexpected, then we have to change with it. When we view the wildland fire system, we can see that people create safety at the point of work, and this is often done as they react to fires that are changing constantly. Many of our training models are based on asking our fire responders to increase their situational awareness; however, research has begun to show us this may be difficult, given human cognitive limitations, distractions, culture, and the environment itself. Let’s look at the example of structure firefighting (based on a focus-group discussion with U.S. capital city fire chiefs; all following quotes emerged from that focus group). Less than 20 years ago, structure firefighting was an “at-all-costs” operation. Fire responders were expected to “risk everything to save nothing.” There have been a lot of changes to structure firefighting. Rather than full-on attack, “we now map danger zones that we do not enter unless there is clear value” (usually someone to save). Structure firefighters now dedicate safety officers whose sole responsibility is to “look for changes in the operational environment and prevent dangerous actions from happening.” “We no longer go in just to save a house.” Of equal importance, the response is measured to meet the need. A crew is set aside in ready reserve, “waiting to save anyone who needs assistance.” The structure community may have started in the same way as the wildland community, but they have learned and adapted to a life-first approach to operations. A looming question emerges. Why don’t we share the same principles between wildland fire and structure fire? During the discussion with the fire chiefs who provided the insights above, it was apparent that they had not recognized this significant difference in their own departments. We should not try to apply the exact tools of the structure community directly to the wildland fire community. Rather, we should understand the importance of learning in improving our normal work. How can we prepare for the variability inherent in fire, and what should we look for? Lessons from other high-risk industries and from structure firefighting would suggest that we assign specific individuals with significant experience and training the role of “observers.” Key researchers who have studied wildland fire operations, Karl Weick and Reuben McDaniel, call on us to invest in these observers as the people tasked to observe and make sense of changes in the work environment. This person, or group of people, could detect subtle changes that might elude a focused fire responder or task-saturated Incident Commander. This new set of eyes and ears increase the capability or safety margin of the operation.

Twisp River Fire Fatalities and Entrapments Organizational Learning Report Page 19 of 28 How else can we build margin? Structure fire responders talk about establishing danger zones; can we leverage this into our operations? A danger zone could be based on one-way-in roads, weather predictions, fuel, or any other aspect of the environment that might influence safety on the ground. To a large degree we are identifying these hazards, but it is not ingrained in a trained response nor is it a routine or default option for our fire responders. We recommend pursuing this concept further, recognizing that doing so will require practical and cultural innovations as well as extensive public dialogue. Conclusion Part A of this document is intended to help us learn how and when to be more deliberate in our decisions and actions; convert raw data into intelligence upstream; figure out ways to relieve pressure from positions in the system that carry the heaviest work load (e.g., ICT3s); and gain a better understanding of how to improve actions in complex adaptive systems. These improvements may help us in the short term to prevent accidents. We are realizing that broader, systemic change is needed concerning the way we interact with fire if we are to reduce accidents and incidents to the fullest extent possible. Part B provides ideas about how we begin to shift toward this new vision for wildland fire. We have a history of being successful at keeping fires small. However, for many reasons, today’s fires are more resistant to control. Intuitive actions common to past efforts may fail when the environment delivers rapid growth that is beyond the capacity of fire responders to predict and adapt. Explosive fire growth is becoming common, yet we are still relying upon strategies and tactics based on the fires of yesterday. We must create the ability to recognize when different approaches are needed and then safely and successfully apply those measures. Fire ecology research and our experience have shown that fire is a natural part of the landscape. We are discovering that our fire suppression actions may need to better account for this current landscape. We find that fires are larger and more severe; more structures are threatened; and our firefighting resources are increasingly stretched. For both practical (safety and cost) and ecological reasons, aggressive fire suppression may not be the best course of action in all situations. Selecting the correct response must consider risk to firefighters, the public, and values at risk—in that order. We envision landscapes that are fire resilient. Fire-resilient landscapes would lessen risks to fire responders. In the WUI, fires could burn around homes without doing appreciable damage or requiring fire responders to weigh heavy risks. To initiate change, as an interagency fire family we need to clearly define our long-term vision for the future. The vision must be sufficiently clear such that we can take actions from where we stand to work toward the target. The keystone piece of this vision was clarified at Twisp River. Three fire responders died protecting homes. Incentives, past successes, the desire to save property, and other factors contributed to the tragic outcome. How do we reduce the chance of a similar tragedy from happening again? We can improve the ability of fire responders to better understand the complexities of wildland fire. We can give our ICT3 leaders the updated training, expert staff, and modern tools to meet the responsibilities we ask them to fulfill. We can remove incentives to risky action and consider placing more risk- assessment responsibility on other parts of our agencies. We can provide mentoring to build the Twisp River Fire Fatalities and Entrapments Organizational Learning Report Page 20 of 28 flexible decision-making and interpersonal skills needed in dynamic wildfire environments. We propose a dialogue among all stakeholders that helps interested parties to understand the risks involved with wildland fire operations. Collaboratively working toward implementation of this long-term vision will require setting deadlines and sticking to them. There is tremendous intellectual capital, passion, and leadership capability within our interagency fire system. Out of our efforts to understand the tragedy of the Twisp River Fire, we must draw knowledge and inspiration for the work ahead.

Twisp River Fire Fatalities and Entrapments Organizational Learning Report Page 21 of 28 Safety Action Plan Learning from an incident like Twisp River requires a deep examination of our daily operations and what is considered “normal work” as well as a better understanding of the many influences surrounding what we do and why. During this examination, weaknesses in our work system are often identified as well as possible changes that may reduce the possibility of another event like Twisp River happening in the future. The changes are designed to improve system-wide resilience, and they are presented as recommendations in this Safety Action Plan. There are ten total recommendations. The first six are focused on short-term/operation actions to improve our field operations. The last four are focused on longer-term/organizational actions that leadership can take to promote organizational risk management for a safer wildfire response environment. Each of the ten recommendations listed has been vetted with the part of the firefighting community it would affect most to ensure the recommendation is possible and makes sense to those who will be implementing the changes associated with it. These recommendations were presented to the Interagency Learning Review Board where they were discussed and vetted by both DNR and Forest Service leadership. The Safety Action Plan provides readers with the group/ entity tasked with completing the given recommendation, the specific action required, and a brief description of the recommendation. Operational (Field) Action Plan Wildland fire communications The Twisp River Learning Review identified problems with the geographical area communications system and protocols related to the recent combination of the Okanogan and Wenatchee National Forests and nature of interagency dispatch. A team of experts has been assembled to create a communications plan and set of protocols that are workable and easily understood by fire responders of all agencies and partners in the geographic area. Focus groups and leadership indicated the need to determine if this type of problem is pervasive throughout the wildland fire system. We recommend that a working group be created to map the problem; identify key issues that can be fixed; identify programs that are already underway; and develop a plan to implement meaningful changes. At a minimum, this working group should consider the issues uncovered in the Twisp River Learning Review, which include dispatch protocols, communications systems, and the importance of soft skills related to communications. Provide fire responders with better intelligence information Rapidly changing fire behavior and incident complexity make it difficult to incorporate an abundance of raw data, such as morning weather and fire behavior briefings, into decision-making in real time. The working group should explore ways to distill and simplify raw data into timely, critical intelligence information that can be easily factored into decisions about the commitment to act (e.g., weather data summarized with a forecasted effect on fire behavior so that it is easy to factor information into decisions related to the plan or changes in the plan). At a minimum the

Twisp River Fire Fatalities and Entrapments Organizational Learning Report Page 22 of 28 working group should explore technological solutions that put this intelligence directly into the hands of firefighters. Scenario-based training Wildland firefighters should not have to rely solely on basic training and experience gained by trial and error in dangerous real-world environments to facilitate learning. It is also widely accepted that student comprehension is far lower when teachers fail to utilize instructional strategies that match a student’s learning style.25 This suggests that to facilitate more effective individual and organizational learning, a variety of learning products and types need to be developed. A concept paper will outline a scenario-based virtual training system that will allow individual users to put themselves “on the ground” in past incidents that resulted in either a fatality or accident or user-created scenarios that practitioners can create themselves. We propose to use the Twisp River incident as the pilot scenario for this training system. The Twisp River incident also illustrated the powerful allure of protecting homes in firefighter decision-making/actions. Training scenarios specific to wildland-urban interface risks, watch-out situations, tactics, and strategies are needed. First-year firefighter and driver training standards Training standards and delivery should be reviewed nationally, especially with regard to first-year firefighter and militia training. There is a need for a formal review of the national standards and method of delivery of this training. Engine driving training standards should be consistent across the nation, and a national system to track driver qualifications would be beneficial. This may entail including driver qualifications in the national Incident Qualification and Certification System (IQCS). Experiential emergency driving training The Twisp River incident is not the first but is hopefully the last time a crew may have to negotiate a road in limited visibility. Experiential training for engine crews should include risk management for module leaders to help them better understand the fire conditions we face today and recognize indicators when it is time to disengage, or to not engage when it is unsafe, or when there is low probability of suppression actions to be effective. Operations in some high-risk industries commonly include egress training from specialized vehicles. The likelihood of firefighting vehicles becoming disabled for any variety of reasons exists. While no evidence was found to conclude that egress training would have made a difference at Twisp River, the complex nature of wildland fire points to a need to standardize egress training and to provide it to crews in the future.

25 Morgan, H. 2013. “Maximizing Student Success in Differentiated Learning.” The Clearing House: A Journal of Educational Strategies, Issues, and Ideas. Volume 87, Issue 1: 34-38. Tomlinson, C.A. & McTighe, J. 2006. Integrating Differentiated Instruction and Understanding by Design. Association for Supervision and Curriculum Development: Alexandria, VA. Twisp River Fire Fatalities and Entrapments Organizational Learning Report Page 23 of 28 Develop ways to better support Type 3 Incident Commanders Wildland fire leadership, in partnership with agency leadership, will seek ways to take pressure off of ICT3s in rapidly emerging Type 3 incidents to enable more focus on the risk in the operational environment. The interagency wildland fire community will collaborate in the development of systemic improvements in initial attack of emerging Type 3 incidents. Specific activities include (1) engaging the wildland fire community to explore the existence or development of technological tools to enhance the ability of fire responders to maintain better situational awareness and (2) checking with National Association of State Foresters (NASF) members, for example. Explore ways in the off-season to help provide the Incident Commander with organizational risk management expectations through dialogue with duty officers, agency administrators, and other leadership. Suggested examples emerging from the focus groups include the following: develop a protocol (using a tool like the DNR helitack report, Weather, Action, Situation, Plan (WASP); Stop, Think, Act, Reflect (STAR); Observe, Orient, Decide, Act (OODA) Loop; or Life First, (Stop, Think, Talk, then Act); etc. to be used by the IC at an assigned temporal benchmark (e.g., 30 minutes). Organizational (Leadership) Action Plan Develop and incorporate pre-fire risk and danger zone assessment tools A diverse working group will be assembled to develop ways to incorporate organizational risk assessment tools, including field and operational verification and public engagement processes. This should include pre-identifying danger zones such as through risk avoidance methodologies currently in use in British Columbia wildland fire responses and in structure firefighting. Consider implementing products developed by Research Ecologist Matt Jolly (RMRS) et al. and/or other similar models, which provide risk awareness and/or assessment prior to commitment of resources on wildland fire responses during extreme conditions. These tools can be used to facilitate a discussion to determine when conditions create a situation where risk is high and therefore assignment of resources and/or response should be measured to account for higher risk (using concepts such as DRAW-D) and likelihood of success. Use of this model would necessitate a pre- season discussion with all stakeholders, cooperators, and partners to identify a set of thresholds that make sense for the local area. The result of this work should be to develop tools that lead to risk-informed fire engagement that is understood by responders and communities alike. Success will be indicated if the degree of engagement is determined through agreement that the values-at-risk justify the risk associated with the plan and there is a high probability of success. This information could be packaged and distributed to all parties involved (public, agency administrators, dispatch, duty officers, and fire responders) through an instantly accessible and easy-to-understand method (e.g., a phone app). Detect and study patterns within the current system: Conduct a broad spectrum learning review There is an existing body of information from accidents, incidents, and normal work stories. This review will combine information and results from multiple studies to better understand work- related conditions that can be improved in the wildland fire system as well as identify what is going well. This review will focus on how we are currently learning from work events and how we can Twisp River Fire Fatalities and Entrapments Organizational Learning Report Page 24 of 28 improve individual and organizational learning for the purpose of prevention. The first phase of this review will be to prepare a proposed plan of action for leadership approval. Conduct a national wildland fire safety cultural change initiative Based on our current understanding of the role of assumptions in culture, we recommend that we conduct a National Wildland Fire Safety Cultural Change Initiative for wildland fire operations similar to the US fire administration National Safety Cultural Change Initiative FA-342 written for structural fire operations (April 2015) and Safety Culture in Nuclear Installations (IAEA-TECDOC 1329). Develop the next level of long-term leader’s intent that provides increased margins of safety Meeting the challenges of today’s dynamic fire environment requires a vision statement for the long-term future that includes an updated set of assumptions that embrace complexity and create a resilient fire environment, including the WUI. We recognize that the public perception and expectation to protect homes, the basic characteristics of firefighting culture, and a changing and complex fire environment each contribute to fire responders’ decision-making about safety margin. A successful vision will adapt expectations of firefighters and the public to a more resilient state where firefighters are no longer required to—or feel the need to—take unwarranted risks to put out fires. The Learning Review team recommends that interagency discussions take place at a high level to understand interconnected cultural practices and determine what the cultural shift will look like in the future in preparation for drafting the scheduled update of the Cohesive Strategy. 1. Create an iterative, responsive dialogue that is in the spirit of the Cohesive Strategy but provides the next level of leaders’ intent needed for tangible change. 2. Building from the dialogue, bring together interagency teams and stakeholders to create targeted three-, five-, and ten-year plans that will result in creating a fire-resilient landscape. Representatives from the research community, marketing specialists, home/structure insurance representatives, legal representatives, political leaders, city zoning and planning experts, and other representatives and specialists should be tasked with creating the steps necessary to meet the targeted end state.

Twisp River Fire Fatalities and Entrapments Organizational Learning Report Page 25 of 28 Appendix Training and Qualifications Driver qualification The driver of the engine involved in the burnover had over a decade of fire experience and held a certificate of completion of the classroom training for engine operation. The certificate reads, “R6 Subject Matter Expert Supplemental Training: For the operation of vehicles 17,501# to 26,000# GVWR.” The Pacific Northwest Region (Region 6) of the Forest Service has a supplemental requirement to the national training standard for wildland fire engine operation. The Region 6 supplemental requirement mandates completing four hours of supervised driving under “actual conditions” before the driving test can be administered. This regulation applies to vehicles that fall into the Gross Vehicular Weight Rating (GVWR) from 10,000 pounds to 26,000 pounds.26 The term “actual conditions” is not defined in the regulation. The driver was actively working toward meeting the additional requirement at the time of the incident. The driver had been a red-carded firefighter since 2004 and had the third-most fire experience on the engine, behind the Captain, who was on sick leave, and the Assistant Captain, who was tasked with other duties by the Incident Commander once the engine arrived on the fire. Supervisors commonly task less-experienced firefighters with driving an engine to become familiar with it in case they are called upon to move the vehicle in an emergency situation. This is normally done in low-risk situations under the direct supervision of a qualified driver. Additionally, agency policy permits operation of vehicles by non-certified drivers in an emergency when great risk is evident. Quality of pre-season training The surviving Forest Service crew member expressed concern regarding the quality of his training as a first-year firefighter. In a statement he said, “The Forest Service had cut Guard School,” which is the instructor-led basic first-year firefighter training. The local National Forest had opted to use the blended version of the training (comprised of online training for the classroom portion and an instructor-led live-fire exercise for the field portion) instead. The following summarizes a discussion that the surviving crew member had with the Learning Review team: When he commented to his supervisors that he did not feel prepared, he was told that the best training for firefighters was on-the-job training. The fire season was pretty slow until August, and then it became extremely active very quickly. He felt as though he wasn’t as prepared as he would have liked to be going into the Twisp River Fire. He felt very strongly that the basic fire training to prepare first-year firefighters needs to be more thorough. Going forward, it is logical to expect the survivor to speak to other firefighters who may find themselves in similar situations. He feels compelled to point out the deficiencies he perceives to exist in the current minimum standards.

The surviving crewmember completed the online training consisting of courses S-130, S-190, and L- 180. These courses are considered the minimum requirements to hold a red card, which qualifies

26 Gross Vehicle Weight Rating. Twisp River Fire Fatalities and Entrapments Organizational Learning Report Page 26 of 28 someone to be a first-year firefighter.27 Additionally, the Forest held the one-day field “live-fire exercise” to complete this training. When on-the-job training was discussed with focus group participants, a question arose whether this training model would prepare non-primary fire employees (people from other disciplines such as recreation) adequately. Would these firefighters be less likely to receive thorough on-the-job training because fire is not their full-time job? National and Regional fire leadership expressed similar concerns regarding adherence to the approved minimum national training standard. They agreed that there is a need for a formal review of national standards and method of training delivery, especially for first-year firefighters. Emergency driving training opportunity The Learning Review team identified an additional training opportunity regarding engine egress in an emergency situation. The Twisp River narrative describes the driving conditions experienced by crews evacuating the fire down Woods Canyon Road behind Engine 642 (mishap engine): ‘The steering wheel was so hot, I wished I had my gloves on.’ Traveling down Woods Canyon Road was treacherous for the entrapped engines because of the heavy smoke and fire. COOP Engine-1 and Contractor Engine-1 reported heavy smoke and conditions were black as night. They could only see a few feet past the hood of their vehicle, and conversations inside the engines were to ‘go slow; go slow. Stay left, wheels in the ditch. Everything bad is to the right; stay left; stay left.’ ‘I don’t care if I cave in the left side of my engine, I’m staying left.’

The crew of this engine had to innovate a solution to a problem they had not foreseen. The emergency conditions required that they proceed down Woods Canyon Road, and they devised the safest way they could think of to accomplish this task. It is likely that this is not the first but is hopefully the last time that a crew may have to negotiate a road in limited visibility. We have an opportunity to learn from their innovation. But more importantly this reinforces the need to not allow fire personnel to accept the risk of being on dead-end roads when there is a high potential for fire to cut off egress. We need to reinforce through training and protocols the need to recognize these situations, how to mitigate the risk, and then to know when to not engage. We have the responsibility to ensure that we do not allow fire personnel to be in emergency egress situations. We need to provide the necessary training and required protocols to eliminate the perceived pressure that may drive spur-of-the-moment decisions to accept unacceptable risk. It is an unfair burden to place on our fire personnel to make these calls, and we need to ensure that Incident Command has the necessary training and qualifications to make these calls. An additional topic of discussion was vehicle egress training. Operations in other high-risk industries commonly include egress training from specialized vehicles under emergency circumstances. While no evidence was found to conclude that egress training would have made a difference in this case, the complex nature of wildland fire points to a need to standardize egress training and to provide it to crews in the future.

27 Go to http://onlinetraining.nwcg.gov/node/177 Twisp River Fire Fatalities and Entrapments Organizational Learning Report Page 27 of 28 No ethanol present before accident Autopsies were performed on August 25, six days after the Twisp River deaths. According to the autopsy report, one of the deceased crew members—not the driver—showed a blood alcohol concentration (BAC) of 0.02. In a later interview with a Forest Service doctor, the coroner stated the reading was likely due to a secondary phenomenon called postmortem ethanol production, which can give readings as high as 0.10 BAC. In the coroner’s opinion, the deceased crew member did not have any ethanol in his system at the time of his death.

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