Firefighting errors kill, over and over
Seattle Times staff reporters
The report is blunt.
Firefighters who die wrestling blazes in national forests and grasslands keep falling victim to the same series of mistakes:
Poor leadership. Inadequate instructions. Unrecognized potential for explosive fire. Poor emergency-escape plans.
The study's authors, a U.S. Forest Service task force, hope to prevent such tragedies. They urge immediate changes — from applying lessons learned in close calls, to keeping experienced woodsmen on the fire lines.
The year of the report: 1957.
Nearly a half-century later, the same pattern of missteps helped trigger the July 10 deaths of four firefighters along the Chewuch River Valley in Okanogan National Forest. Safety lessons, seemingly, have not been learned.
The five federal wildfire agencies have known for decades how and why men and women die on America's fire lines. The reasons appear in their studies and accident reports and in surveys with firefighters and their leaders.
And since the death of 14 firefighters on Colorado's Storm King Mountain in 1994, the entire firefighting machine has worked to shift the focus to safety. Firefighters are encouraged to decline dangerous assignments, they can report safety problems anonymously, and urgent safety "alerts" are now posted online.
Yet officials have not fixed many of the fundamental problems their own research deems critical to firefighter safety.
While firefighters plead for accountability, the tight-knit wildfire-fighting family sometimes shields its own rather than applying tough love. Simple solutions are forgotten or dismissed. More complicated ideas are pondered, then shelved:
• Psychologists three years ago showed firefighters can more successfully remember the job's core safety rules if they are distilled and reworded. But the 10 fire orders and 18 warning signs that constitute the firefighter's bible of safety remain untouched.
• Firefighters asked in 1996 for more practice deploying their emergency aluminum and fiberglass shelters. But mandatory practice is still just a few minutes once a year.
• Although a 1998 federal report urged putting people on non-hazardous duty while an accident is investigated, nearly every firefighter and leader at this year's fatal Thirty Mile fire was soon working other fires. One key decision-maker that fatal day was given even more responsibility a month later — despite not having met all the job requirements.
• Officials have complained on and off for 44 years that the fire corps was losing experienced workers. Yet Forest Service policy prohibits hiring experienced firefighters permanently if they are older than 35 because of pension issues.
• Despite internal pressure for several years, the fire service does not require firefighters to receive training in decision-making under stress and other human-behavior areas.
In a profession that asks firefighters to balance aggressiveness and caution, study after study says top leaders must force changes in safety practices. But several people high in safety and training circles concede progress has, at times, been glacial.
"There were days when I felt very good about our progress, and there were days when I felt, 'Damn, why don't we just do this?' " said Steve Holder, who retired this year from a job overhauling federal firefighting-safety rules.
Jim Cook, training-projects coordinator for the Forest Service at the National Fire Safety Office in Boise, was frank: "I'd give us a C-plus. There've been a lot of things implemented — and a lot of things that weren't that should have been.
Making changes across many agencies is "like turning an aircraft carrier around," he said
And unless mistakes lead to injuries, a fire operation is seldom critiqued, said Curt Braun, a University of Idaho psychology professor who has studied wildfire mishaps. "There isn't a CEO of fire" who can push through needed changes, he said.
All that is little consolation to the people closest to last summer's tragedy.
"While I don't want to see anybody go to jail, my son did quite a bit worse than that," said Ken Weaver, whose son Devin had 21 days of firefighting experience when he died July 10. "Unless we do something to hold these people's feet to the fire, it's just going to happen again."
Pattern is the same
Wildland firefighting is inherently treacherous work. Falling trees, heart attacks, breathing smoke, even snakebites can injure firefighters. Yet for years, the government has recognized a pattern behind the most serious injuries.
Trouble typically occurs on small fires tended by tired crews when conditions change. Things go bad because firefighters have violated safety rules or missed warning signs.
Such was the case July 10. After a long stretch in which many firefighters had been up for 30 hours, flames cut off the only escape route for 14 Forest Service crew members and two hikers. Firefighters Tom Craven, 30; Karen FitzPatrick, 18; Devin Weaver, 21; and Jessica Johnson, 19, died.
They are among 400 since 1910 who have been overrun by flames and died while fighting fires for agencies known collectively as the fire service: the U.S. Forest Service, Bureau of Land Management, National Park Service, Bureau of Indian Affairs and Fish and Wildlife Service.
Decades of experience have given these agencies a sophisticated understanding of how fire moves and how to fight it. Safety is the watchword during morning briefings, on Web sites, on bulletin boards, on water bottles.
"I've never seen an agency that more consistently speaks safety than this one," said Tony Kern, a Forest Service accident specialist who helped investigate the Thirty Mile Fire.
But for many firefighters the call to be safe is often drowned out by the drive to extinguish flames. A voluminous 1996 study of 1,000 firefighters, prompted by the Storm King disaster, framed the problem:
• Forty percent of firefighters said getting the job done was as important as safety. Another 15 percent said it was "policy" to break rules to put out a fire.
• Forty percent of those on low-level crews, such as one trapped in July, said they didn't receive mandatory briefings about escape routes and safety zones — places where flames can't harm firefighters — in half the fires they fought.
• Most close calls are never reported, mostly to avoid paperwork.
• More than 25 percent of the firefighters said they and their supervisors often or very often ignore the 18 standard warning signs while fighting fires.
"One of the damning things here were how many areas needed work," said Philip Schaenman, a Virginia-based consultant who led the 1996 survey and follow-up reports. "(The federal agencies) are doing 90 percent of what they need to do, but we didn't find just two or three glaring deficiences in that last 10 percent. There were a whole lot of problems."
Three years later, firefighting experts for all five agencies reiterated the report's message after a workshop on safety. "Safety is not number 1 on the fire line," the group's conclusions read. "It is more like the 4th or 5th strongest reinforced behavior. Presently, putting the fire out is number 1."
Several safety officials contend that much has changed since that 1999 workshop. But in the Thirty Mile Fire, investigators said, all 10 safety orders were violated.
"One must question the field-level understanding or commitment to the stated core value (of safety)," said the formal report released yesterday. "One crew member, when asked about the apparent apathy toward the guidelines, responded, 'everyone knows that these things are just guidelines and can't always be followed.' "
Role of training
Many experts trace safety lapses back to training.
Rookies on the fire line receive 32 hours of class work and field exercises, and must be able to deploy a fire shelter in 20 seconds. But there is little firsthand fire experience, and no realistic alternative, before they're sent out to wild flames.
Last year, President Clinton's National Fire Plan called for $1.8 billion, in part, to hire 5,300 more firefighters. But none of the money was earmarked for enhanced training. Yet Forest Service reports dating back to 1995 have suggested longer training sessions.
And while firefighters are taught the 10 rules and 18 warning signs, experts contend those commandments are unrealistic, esoteric and tough to recall under stress.
"Something's not sinking in," said Paul Gleason, interim national director for firefighter safety with the National Interagency Fire Center in Boise.
Others said training focuses on technical skills rather than the human factors such as following or questioning orders or recognizing fatigue. At Thirty Mile, for example, some firefighters were convinced well before the crisis point that it was time to leave. Others said out loud the crew had lost the battle. But no one pressed the point.
"Newcomers sometimes catch stuff that old-timers miss," said Karl Weick, an organizational-behavior professor at the University of Michigan who studies wildfire decision-making. "But newcomers, for good reason, also tend to shut up about their suspicions, lest they look really dumb."
Forty-four years ago a Forest Service task force urged better supervisory training. Little has changed. A February 2001 report concluded leadership is poorly taught — when taught at all.
General fire-agency guidelines don't require on-the-ground fire bosses or superiors to take courses in how to manage people. Such training, when available, is voluntary and "delivered far too late in people's careers," the report said.
And the importance of leadership has only increased. The General Accounting Office this year estimated risky fuel conditions existed on 211 million acres — roughly one-third of all federal land.
There seems to be a dearth of experience among bosses. Old hands with the skill to handle tricky situations are leaving behind a corps of leaders with poor institutional memory, said Weick, who wrote an influential re-analysis of Arizona's 1990 Dude Fire, in which six firefighters died.
On July 10, along the Chewuch River, crew members said they sensed danger before 14 became trapped, and looked to leaders for guidance.
"I had a feeling that they know what they're doing," said Andy Floyd, a engine-crew firefighter that day. "If we need to get out then they'll tell us to get out."
Thom Taylor, a squad boss trapped by the fire, said: "I think it was lack of leadership. Who was out there sticking up for us all day?"
Pleading for accountability
After the 1994 Storm King disaster, the worst in U.S. wildfire-fighting history, the Occupational Safety and Health Administration was direct: Wildfire agencies "must develop a policy of zero tolerance" for safety infractions.
Two years later, in the agencies' survey, firefighters begged to be held more accountable for breaking safety rules.
In 1998, another phase of that survey and report recommended: "Certainly there should be 'due process' when safety incidents occur, but, in the meantime, individuals should be put on administrative leave or returned to a non-fire job while a casualty, entrapment or near miss is investigated."
Mandatory leave is routine for police officers involved in deaths — not as punishment but to let the department determine whether mistakes were made. Yet a few weeks after the Thirty Mile deaths, nearly every healthy firefighter who had been there was back to battling flames.
Ellreese Daniels, the incident commander who took over late in the day, is an exception. He's since been moved to a non-firefighting job. But Pete Kampen, who led the crew as manager-in-training under Daniels' supervision, was temporarily promoted to crew boss while fighting fires mid-August near Leavenworth. His supervisor, Fire Management Officer Roger Wallace, Leavenworth Ranger District, acknowledged Kampen hadn't yet completed the pre-requisites for that position.
"Your self-esteem can be really hurt by a tragedy like this," Wallace said. "It was our way of showing him that we do have faith in his abilities."
Wallace's intentions aside, some firefighters who work in and around Leavenworth — and some who fought at Thirty Mile — said they came away with the message the agencies hoped to avoid: Accountability is second to protecting your own.
And families of the deceased were outraged.
"When something like this happens, they need to be put in another position — or fired," said Kathie FitzPatrick, whose daughter Karen died July 10. "I'm sorry, but when you make mistakes this severe, you shouldn't just go back to work."
After six died at Arizona's Dude fire in 1990, officials called for change. When 14 died at Storm King four years later, officials promised history would not be repeated. Now with four more dead in a lonesome canyon, some officials, family members and surviving firefighters again demand change — but expect little.
"They may squirm a lot for awhile," FitzPatrick said of the fire corps, "but they have too many excuses for why these things weren't done before."
Dale Bosworth, chief of the Forest Service, promised this time would be different.
"I went to my first fire 40 years ago," he said yesterday in a brief interview. "I have lots of firefighting experience. Not all of my predecessors did."
He reiterated his sorrow over the deaths at Thirty Mile, adding "I can't help what people think. They'll just have to judge us by our actions."