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Risk Management 2007


They must find people's inaccurate assessments, wrong decisions and bad judgments ... To explain failure, do not try to find where people went wrong ... – PowerPoint PPT presentation

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Title: Risk Management 2007

Risk Management2007
Historic Trends
  • Based on Safety Gram data - from 1990-2006
  • 306 Individuals died in this 17 year period.
  • Leading causes of death
  • Aircraft Accidents 72 deaths, 23
  • Vehicle Accidents 71 deaths, 23
  • Heart Attacks 68 deaths, 22
  • 65 of these were volunteer firefighters
  • Burnovers/Entrapments 64 deaths, 21

Historic Trends
  • 1990-2006 Federal - 73 deaths
  • Burnovers 39.7
  • Aircraft Accidents 19.2
  • Heart Attacks 13.7
  • Vehicle Accidents 11

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Historic Trends Conclusions
  • 40 of federal fatalities were in burnovers
  • Twice the number of the next highest category,
    aircraft accidents
  • Driving fatalities increased 107 from 1990 thru
    1998 vs. 1999 thru 2006
  • Latter period included 3 multi-fatality driving
  • Heart attacks are a lesser but still significant
    cause of federal firefighter deaths

2007 Year in Review
2007 Forest Service events
  • 2 Forest Service fatalities
  • Both driving in Region 8
  • one returning from incident
  • one returning from training
  • 22 entrapped firefighters
  • 6 burn injuries
  • 4 fire shelters deployed
  • No heart attacks

Forest Service Entrapments2007
  • Who became entrapped?
  • Where did these entrapments occur?
  • In the WUI or elsewhere
  • What level of incident management was in place
    when the entrapments occurred?

Who Became Entrapped
Where Did Entrapments Occur?
  • 25 in WUI situations
  • 75 outside the WUI

Level of Incident Management2007 Entrapments
  • Figure out ways to reduce driving exposure
  • Emphasize use of seat belts
  • Emphasize proper use of PPE
  • Maintain fitness programs and health screening
  • Firefit

  • Maintain emphasis on entrapment avoidance
  • Use case studies and STEX
  • Focus firefighters on operational risk assessment
  • But dont develop another checklist
  • Engage your Incident Management Teams

Shifting Gears
  • How do we know all the information just
  • Why should we pay attention to near miss
  • What are the best ways to learn from unintended

Accident PyramidH.W. Heinrich - 1931
Current Thinking
  • Managing the Unexpected Assuring High
    Performance in an Age of Complexity
  • Karl Weick and Kathleen Sutcliffe
  • High Reliability Organizing (HRO)
  • Managing the Risks of Organizational Accidents
  • Dr. James Reason
  • Swiss Cheese Model
  • Components of a Safety Culture

Current Thinking
  • The Field Guide to Human Error Investigations
  • Sidney Dekker
  • Old view vs. new view of Human Error

High Reliability Organizing
  • HROs operate in high risk environments
  • but they seem to have less than their fair
    share of accidents
  • Hallmarks of an HRO
  • Preoccupation with Failure
  • Reluctance to simplify
  • Sensitivity to operations
  • Commitment to resilience
  • Deference to expertise

Active versus Latent Failures (Reason, 1990)
  • Latent Conditions
  • Excessive cost cutting
  • Inadequate promotion policies
  • Latent Conditions
  • Deficient training program
  • Poor crew fitness

Unsafe Supervision
  • Latent Conditions
  • Poor CRM
  • Mental Fatigue

Preconditions for Unsafe Acts
Unsafe Acts
  • Active Conditions
  • Inadequate communications
  • Underestimated fire behavior

Failed or Absent Defenses
  • Accident Injury

Elements of a Safety Culture
  • Four critical elements
  • James Reason Managing the Risks of
    Organizational Accidents
  • Reporting Culture
  • Just Culture
  • Flexible Culture
  • Learning Culture
  • A Safety Culture is one that allows the boss to
    hear bad news Sidney Dekker
  • Bad news has to reach the boss
  • What exactly counts as bad news?

Just Culture
  • A culture of justice for self-reporting errors.
    An ethical workplace where people are encouraged
    (even rewarded) for disclosing errors and
    protected against reprisals for normative human
    error regardless of outcome.
  • James Reason

Human Error
  • It has been estimated that 70-80 of all
    accidents involve some form of human error
  • There are different types of human error
  • Decision error
  • Skill-based error
  • Perceptual error

Human Error
  • Human error is a consequence not a cause.
    Errors are shaped by upstream workplace and
    organizational factors.. Only by understanding
    the context of the error can we hope to limit its
  • James Reason

Human Error and Investigations
  • .unlike the tangible and quantifiable evidence
    surrounding mechanical failures, the evidence and
    causes of human error are generally qualitative
    and elusive. Furthermore, human factors
    investigative and analytical techniques are often
    less refined and sophisticated than those used to
    analyze mechanical and engineering concerns.
  • FAA Report Wiegmann and Shappell

Old View of Human Error
  • Human Error is a cause of accidents
  • To explain failure, investigations must seek
  • They must find peoples inaccurate assessments,
    wrong decisions and bad judgments
  • Sidney Dekker

The Bad Apple Theory
  • Complex systems would be fine, were it not for
    the erratic behavior of some unreliable people
    (bad apples) in them.
  • Human errors cause accidents humans are the
    dominant contributor to more than two thirds of
  • Failures come as unpleasant surprises. Failures
    are introduced to the system only through the
    inherent unreliability of people.
  • Sidney Dekker

New View of Human Error
  • Human Error is a symptom of trouble deeper inside
    a system
  • To explain failure, do not try to find where
    people went wrong
  • Instead, investigate how peoples assessments and
    actions would have made sense at the time, given
    the circumstances that surrounded them
  • Sidney Dekker

New View of Human Error
  • Human error is not a cause of failure. Human
    error is the effect, or symptom, of deeper
  • Human error is not random. It is systematically
    connected to features of peoples tools, tasks
    and operating environment.
  • Human error is not the conclusion of an
    investigation. It is the starting point.
  • Sidney Dekker

Whats Wrong With This Picture?
  • Why are reports that cite violations of the
    Standard Fire Orders meaningless?
  • Why is the phrase he or she lost situation
    awareness meaningless?

Hindsight really is perfect!
  • One of the most popular ways by which
    investigators assess behavior is to hold it up
    against a world they now know to be true.
  • We match our hindsight of peoples performance
    with a procedure or collection of rules
  • Peoples behavior was not in accordance with
    standard operating procedures that were found to
    be applicable to the situation afterwards.

But we dont learn anything.
  • The problem is that these after-the-fact-worlds
    may have very little in common with the actual
    world that produced the behavior under
    investigation. They contrast peoples behavior
    against the investigators reality, not the
    reality that surrounded the behavior in question.
    Thus, micro-matching fragments of behavior with
    these various standards explains nothing it
    only judges. --Sidney Dekker

What about loss of situation awareness?
  • If you lose situation awareness, what replaces
  • There is no such thing as a mental vacuum.
  • The only way to lose awareness is to become
  • So.people didnt lose awareness, rather the
    awareness that they had differed from reality.
  • Why?????

People Create Safety
  • Safety is never the only goal in systems that
    people operate.
  • Trade-offs between safety and other goals often
    have to be made under uncertainty and ambiguity.
  • Systems are not basically safe. People in them
    have to create safety byadapting under pressure
    and acting under uncertainty.
  • Sidney Dekker

Doctrine and CultureHow does it all fit together?
  • Rule-based Culture
  • Invariably found to be in violation of own rules
    in the event of an investigation
  • Safety programs become more restrictive and
    compliance based
  • Checklist saturation
  • Risk aversion in response to fear of liability

So What Is Doctrine?
  • Doctrine is the expression of fundamental
    concepts and principles that guide planning and
  • Principles are intended to help us develop the
    ability to make good choices.
  • Principles need to be well stated to clearly
    represent our work, the environment, and the

Foundational Doctrine Guiding Fire
SuppressionThe Operational Environment
  • 1.The Forest Service believes that no resource or
    facility is worth the loss of human life. We
    acknowledge that the wildland firefighting
    environment is dangerous because its complexity
    may make events and circumstances difficult or
    impossible to foresee. We will aggressively and
    continuously manage risks toward a goal of zero
    serious injuries or fatalities.

On the practical side
  • Doctrine provides a shared way of thinking about
    problems, but does not direct how problems will
    be solved.
  • Rules exist, but in the context of Policy, laws
    and those items that are too important to leave
    to discretion, interpretation, or judgment.

On the practical side
  • Doctrine allows firefighters to take risk
    successfully as opposed to restricting action
    considered to be risky through rules

What is Accountability
  • Is it the same thing as punishment
  • What types of things should people be punished
  • What does punishment accomplish?
  • Punishing is about stifling the flow of
    safety-related information (because people do not
    want to get caught) -- Dekker

  • Accountability should be based on a well defined
    distinction between acceptable and unacceptable
  • The determining factor is not the act, but the
    intent of the actor
  • Evaluation based upon understanding of intent,
    application of principles, and judgment

Learning and punishment dont mix
  • A system cannot learn from failure and punish
    supposedly responsible individuals or groups at
    the same time. --Sidney Dekker

True Safety Lies in Learning
  • Learning is about seeing failure as part of a
  • Learning is about countermeasures that remove
    error-producing conditions so there wont be a
    next time.
  • Learning is about increasing the flow of
    safety-related information.
  • Learning is aboutthe continuous improvement that
    comes from firmly integrating the terrible event
    in what the system knows about itself.

We all make mistakes..
  • ..but how do we learn from them?

New Tools for Learning
  • APA Accident Prevention Analysis
  • More formal, requires full team
  • Carries assurance that no administrative actions
    will be taken if there was no reckless behavior
  • Written report produced that tells a story
  • Includes recommendations
  • FLA Facilitated Learning Analysis
  • Less formal, may be a 3-person team
  • Written report may be produced
  • Sand Table Exercise often produced
  • Does not include recommendations

  • An anonymous reporting system where firefighters
    can voice safety and health concerns.
  • Documents corrective actions taken at the field
    level or provides suggested corrective actions
    for higher level of action.
  • What SAFENET is NOT
  • A forum for personal attacks/defamation.
  • A mechanism to elevate pet peeves.
  • Only used for incidents that need higher level
    corrective action.
  • Interagency criteria established for posting
    determination clearly stated safety and health
    issue necessary for posting.

Near Miss Reporting
  • National submission decline from 2005
  • 2005 -- 180 submissions
  • 2006 -- 155 submissions
  • 2007 -- down to 119 submissions
  • Every report matters!!!

Firefighters Need a Single Handheld Radio
  • The M16 has been the standard infantry weapon for
    U.S. forces outside NATO since 1967.

  • Medical Standards Program
  • SAFENET Administration
  • FireFit
  • Six Minutes for Safety
  • WFSTAR Fire Safety Refresher Training Website
  • Red Book lead for Ch. 7 Safety, Ch. 18 Reviews
    and Investigations, portions of Ch. 13 Training
    Quals, Ch. 15 Equipment
  • NMAC coordination

SHWT Update
  • Energy, Nutrition, and Health Projects (MTDC)
  • Wildland Firefighter Health Safety Reports
  • Nutrition Power Point Brochure
  • Shift Food Study
  • Hydration System Field Study
  • Revision of Fitness Work Capacity
  • Boot Study
  • Powerline Safety Study
  • Requesting Seat Belt Study (human factors
  • Other studies PPE (gloves, pants, shirts), chain
    saw chaps, new Safety Zone research.

SHWT Update
  • New - Incident Emergency Medical Task Group -
    replaces Emergency Medical Support Group.
  • Hazard Tree Tree Felling Task Group
  • Injury/Illness Module in ISUITE input made by
  • Updating Agencys Administrator Guide to Critical
    Incident Management
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