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