Risk ManagementRisk Management20072007

Historic TrendsHistoric Trends

Based on Safety Gram data - from 1990-Based on Safety Gram data - from 1990-2006:2006:

306 Individuals died in this 17 year period.306 Individuals died in this 17 year period. Leading causes of death:Leading causes of death: Aircraft Accidents: 72 deaths, 23%Aircraft Accidents: 72 deaths, 23% Vehicle Accidents: 71 deaths, 23%Vehicle Accidents: 71 deaths, 23% Heart Attacks: 68 deaths, 22%Heart Attacks: 68 deaths, 22%

65% of these were volunteer firefighters65% of these were volunteer firefighters Burnovers/Entrapments: 64 deaths, 21%Burnovers/Entrapments: 64 deaths, 21%

Historic TrendsHistoric Trends

1990-2006 Federal - 73 deaths:1990-2006 Federal - 73 deaths: Burnovers: 39.7%Burnovers: 39.7% Aircraft Accidents: 19.2%Aircraft Accidents: 19.2% Heart Attacks: 13.7%Heart Attacks: 13.7% Vehicle Accidents: 11%Vehicle Accidents: 11%

Historic Trends – Historic Trends – ConclusionsConclusions

40% of federal fatalities were in 40% of federal fatalities were in burnoversburnovers Twice the number of the next highest Twice the number of the next highest

category, aircraft accidentscategory, aircraft accidents Driving fatalities increased 107% from Driving fatalities increased 107% from

1990 thru 1998 vs. 1999 thru 20061990 thru 1998 vs. 1999 thru 2006 Latter period included 3 multi-fatality driving Latter period included 3 multi-fatality driving

accidentsaccidents Heart attacks are a lesser but still Heart attacks are a lesser but still

significant cause of federal firefighter significant cause of federal firefighter deathsdeaths

2007 Year in Review2007 Year in Review

2007 Forest Service events2007 Forest Service events

2 Forest Service fatalities2 Forest Service fatalities Both driving in Region 8Both driving in Region 8

one returning from incidentone returning from incident one returning from trainingone returning from training

22 entrapped firefighters22 entrapped firefighters 6 burn injuries6 burn injuries 4 fire shelters deployed4 fire shelters deployed

No heart attacksNo heart attacks

Forest Service EntrapmentsForest Service Entrapments20072007

Who became entrapped?Who became entrapped? Where did these entrapments occur?Where did these entrapments occur?

In the WUI or elsewhereIn the WUI or elsewhere What level of incident management What level of incident management

was in place when the entrapments was in place when the entrapments occurred?occurred?

Who Became EntrappedWho Became Entrapped

Type of Resource Number of People Number of events Percentage of Total People

Entrapped

Engine Crew Personnel

11 3 50%

Overhead 4 3 18%

Hotshot Crew Personnel

3 1 14%

Private Citizens 2 1 9%

Dozer Operator 1 1 4.5%

Contractor 1 1 4.5%

Where Did Entrapments Where Did Entrapments Occur?Occur?

25% in WUI situations25% in WUI situations 75% outside the WUI75% outside the WUI

Level of Incident ManagementLevel of Incident Management2007 Entrapments2007 Entrapments

Type 1 (37.5%)

Type 2 (25%)

Type 3 (37.5%)

RecommendationsRecommendations

Figure out ways to reduce driving Figure out ways to reduce driving exposureexposure

Emphasize use of seat beltsEmphasize use of seat belts Emphasize proper use of PPEEmphasize proper use of PPE Maintain fitness programs and health Maintain fitness programs and health

screeningscreening FirefitFirefit

RecommendationsRecommendations

Maintain emphasis on entrapment Maintain emphasis on entrapment avoidanceavoidance Use case studies and STEXUse case studies and STEX

Focus firefighters on operational risk Focus firefighters on operational risk assessmentassessment But don’t develop another checklistBut don’t develop another checklist

Engage your Incident Management Engage your Incident Management TeamsTeams

Shifting GearsShifting Gears

How do we know all the information How do we know all the information just presented?just presented?

Why should we pay attention to Why should we pay attention to “near miss” events?“near miss” events?

What are the best ways to learn from What are the best ways to learn from unintended outcomes?unintended outcomes?

Accident PyramidAccident PyramidH.W. Heinrich - 1931H.W. Heinrich - 1931

600

29

10

1 Serious Injury (with disability)/Fatal

Light injury (without disability)

Accident with losses (property/equip)

Incidents

Figure 3. Pyramid of Bird. Source: Geller (1998)

Current ThinkingCurrent Thinking

Managing the Unexpected – Assuring High Managing the Unexpected – Assuring High Performance in an Age of ComplexityPerformance in an Age of Complexity Karl Weick and Kathleen SutcliffeKarl Weick and Kathleen Sutcliffe High Reliability Organizing (HRO)High Reliability Organizing (HRO)

Managing the Risks of Organizational Managing the Risks of Organizational AccidentsAccidents Dr. James ReasonDr. James Reason ““Swiss Cheese Model”Swiss Cheese Model” Components of a ‘Safety Culture’Components of a ‘Safety Culture’

Current ThinkingCurrent Thinking

The Field Guide to Human Error The Field Guide to Human Error InvestigationsInvestigations Sidney DekkerSidney Dekker Old view vs. new view of Human ErrorOld view vs. new view of Human Error

High Reliability OrganizingHigh Reliability Organizing

HROs operate in high risk environments…HROs operate in high risk environments… ……but they seem to have “less than their but they seem to have “less than their

fair share of accidents”fair share of accidents” Hallmarks of an HROHallmarks of an HRO

Preoccupation with FailurePreoccupation with Failure Reluctance to simplifyReluctance to simplify Sensitivity to operationsSensitivity to operations Commitment to resilienceCommitment to resilience Deference to expertiseDeference to expertise

Latent ConditionsExcessive cost cutting

Inadequate promotion policies

Latent ConditionsDeficient training program

Poor crew fitness

Latent ConditionsPoor CRM

Mental Fatigue

Active ConditionsInadequate communications

Underestimated fire behaviorFailed orAbsent Defenses

OrganizationalFactors

UnsafeSupervision

Preconditionsfor

Unsafe Acts

UnsafeActs

Accident & Injury

Active versus Latent Failures (Reason, 1990)

Elements of a Safety CultureElements of a Safety Culture

Four critical elements: Four critical elements: James Reason: Managing the Risks of Organizational AccidentsJames Reason: Managing the Risks of Organizational Accidents

Reporting CultureReporting Culture Just CultureJust Culture Flexible CultureFlexible Culture Learning CultureLearning Culture ““A Safety Culture is one that allows the A Safety Culture is one that allows the

boss to hear bad news” boss to hear bad news” Sidney DekkerSidney Dekker Bad news has to reach the bossBad news has to reach the boss What exactly counts as “bad news”?What exactly counts as “bad news”?

Just CultureJust Culture

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

James ReasonJames Reason

Human ErrorHuman Error

It has been estimated that 70-80% of It has been estimated that 70-80% of all accidents involve some form of all accidents involve some form of human errorhuman error

There are different types of human There are different types of human error:error: Decision errorDecision error Skill-based errorSkill-based error Perceptual errorPerceptual error

Human ErrorHuman Error

““Human error is a consequence not a Human error is a consequence not a cause. Errors are shaped by cause. Errors are shaped by upstream workplace and upstream workplace and organizational factors….. Only by organizational factors….. Only by understanding the context of the understanding the context of the error can we hope to limit its error can we hope to limit its reoccurrence”. reoccurrence”.

James ReasonJames Reason

Human Error and Human Error and InvestigationsInvestigations

“….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 ErrorOld View of Human Error

Human Error is a cause of accidentsHuman Error is a cause of accidents To explain failure, investigations To explain failure, investigations

must seek failuremust seek failure They must find people’s inaccurate They must find people’s inaccurate

assessments, wrong decisions and assessments, wrong decisions and bad judgmentsbad judgments

Sidney Sidney DekkerDekker

The “Bad Apple” TheoryThe “Bad Apple” Theory

Complex systems would be fine, were it Complex systems would be fine, were it not for the erratic behavior of some not for the erratic behavior of some unreliable people (bad apples) in them.unreliable people (bad apples) in them.

Human errors cause accidents; humans Human errors cause accidents; humans are the dominant contributor to more than are the dominant contributor to more than two thirds of them.two thirds of them.

Failures come as unpleasant surprises. Failures come as unpleasant surprises. Failures are introduced to the system only Failures are introduced to the system only through the inherent unreliability of through the inherent unreliability of people.people.

Sidney DekkerSidney Dekker

New View of Human ErrorNew View of Human Error

Human Error is a symptom of trouble Human Error is a symptom of trouble deeper inside a systemdeeper inside a system

To explain failure, do not try to find To explain failure, do not try to find where people went wrongwhere people went wrong

Instead, investigate how people’s Instead, investigate how people’s assessments and actions would have assessments and actions would have made sense at the time, given the made sense at the time, given the circumstances that surrounded themcircumstances that surrounded them

Sidney Sidney DekkerDekker

New View of Human ErrorNew View of Human Error

Human error is not a cause of failure. Human error is not a cause of failure. Human error is the effect, or symptom, of Human error is the effect, or symptom, of deeper trouble.deeper trouble.

Human error is not random. It is Human error is not random. It is systematically connected to features of systematically connected to features of people’s tools, tasks and operating people’s tools, tasks and operating environment.environment.

Human error is not the conclusion of an Human error is not the conclusion of an investigation. It is the starting point.investigation. It is the starting point.

Sidney DekkerSidney Dekker

What’s Wrong With This What’s Wrong With This Picture?Picture?

Why are reports that Why are reports that cite “violations” of cite “violations” of the Standard Fire the Standard Fire Orders meaningless?Orders meaningless?

Why is the phrase Why is the phrase “he or she lost “he or she lost situation awareness” situation awareness” meaningless?meaningless?

Hindsight really is perfect!Hindsight really is perfect!

One of the most popular ways by One of the most popular ways by which investigators assess behavior which investigators assess behavior is to hold it up against a world they is to hold it up against a world they nownow know to be true. know to be true. --Dekker--Dekker

We match our hindsight of people’s We match our hindsight of people’s performance with a procedure or performance with a procedure or collection of rules:collection of rules: People’s behavior was not in accordance People’s behavior was not in accordance

with standard operating procedures that with standard operating procedures that were found to be applicable to the were found to be applicable to the situation afterwards.situation afterwards.

But we don’t learn But we don’t learn anything….anything….

““The problem is that these after-the-fact-The problem is that these after-the-fact-worlds may have very little in common with worlds may have very little in common with the actual world that produced the behavior the actual world that produced the behavior under investigation. They contrast people’s under investigation. They contrast people’s behavior against the investigator’s reality, behavior against the investigator’s reality, not the reality that surrounded the behavior not the reality that surrounded the behavior in question. Thus, micro-matching in question. Thus, micro-matching fragments of behavior with these various fragments of behavior with these various standards explains nothing – it only judges.”standards explains nothing – it only judges.”

--Sidney Dekker--Sidney Dekker

What about “loss of situation What about “loss of situation awareness”?awareness”?

If you lose situation awareness, what replaces If you lose situation awareness, what replaces it?it?

There is no such thing as a mental vacuum.There is no such thing as a mental vacuum. The only way to “lose awareness” is to The only way to “lose awareness” is to

become unconscious.become unconscious.

So….people didn’t lose awareness, rather the So….people didn’t lose awareness, rather the awareness that they had differed from reality.awareness that they had differed from reality. Why?????Why?????

People Create SafetyPeople Create Safety

Safety is never the only goal in systems Safety is never the only goal in systems that people operate.that people operate.

Trade-offs between safety and other goals Trade-offs between safety and other goals often have to be made under uncertainty often have to be made under uncertainty and ambiguity.and ambiguity.

Systems are not basically safe. People in Systems are not basically safe. People in them have to create safety by…adapting them have to create safety by…adapting under pressure and acting under under pressure and acting under uncertainty.uncertainty.

Sidney DekkerSidney Dekker

Doctrine and CultureDoctrine and CultureHow does it all fit together?How does it all fit together?

Rule-based Culture:Rule-based Culture:

Invariably found to be in violation of own rules in Invariably found to be in violation of own rules in the event of an investigation the event of an investigation

Safety programs become more restrictive and Safety programs become more restrictive and compliance basedcompliance based Checklist saturationChecklist saturation

Risk aversion in response to fear of liability Risk aversion in response to fear of liability

So What Is Doctrine?So What Is Doctrine?

Doctrine is the expression of Doctrine is the expression of fundamental concepts and fundamental concepts and principlesprinciples that guide planning and action.that guide planning and action.

Principles are intended to help us Principles are intended to help us develop the ability to make good develop the ability to make good choices.choices.

Principles need to be well stated to Principles need to be well stated to clearly represent our work, the clearly represent our work, the environment, and the mission.environment, and the mission.

Foundational Doctrine Guiding Fire Foundational Doctrine Guiding Fire SuppressionSuppression

The Operational EnvironmentThe 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 sideOn 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 sideOn the practical side

Doctrine allows firefighters to take risk Doctrine allows firefighters to take risk successfully as opposed to restricting successfully as opposed to restricting action considered to be risky through action considered to be risky through rules & checklists.rules & checklists.

What is “Accountability”What is “Accountability”

Is it the same thing as “punishment”Is it the same thing as “punishment”

What types of things should people What types of things should people be punished for?be punished for?

What does punishment accomplish?What does punishment accomplish? ““Punishing is about stifling the flow of Punishing is about stifling the flow of

safety-related information (because safety-related information (because people do not want to get caught)” people do not want to get caught)” -- -- DekkerDekker

AccountabilityAccountability

Accountability should be based on a well Accountability should be based on a well defined distinction between acceptable defined distinction between acceptable and unacceptable behaviorand unacceptable behavior

The determining factor is not the act, but The determining factor is not the act, but the intent of the actorthe intent of the actor

Evaluation based upon understanding of Evaluation based upon understanding of intent, application of principles, and intent, application of principles, and judgment judgment

Learning and punishment don’t Learning and punishment don’t mixmix

““A system cannot learn from failure A system cannot learn from failure and punish supposedly responsible and punish supposedly responsible individuals or groups at the same individuals or groups at the same time.” time.” --Sidney Dekker--Sidney Dekker

True Safety Lies in LearningTrue Safety Lies in Learning

Learning is about seeing failure as part of Learning is about seeing failure as part of a system.a system.

Learning is about countermeasures that Learning is about countermeasures that remove error-producing conditions so remove error-producing conditions so there won’t be a next time.there won’t be a next time.

Learning is about increasing the flow of Learning is about increasing the flow of safety-related information.safety-related information.

Learning is about…the continuous Learning is about…the continuous improvement that comes from firmly improvement that comes from firmly integrating the terrible event in what the integrating the terrible event in what the system knows about itself.system knows about itself.

We all make mistakes…..We all make mistakes…..

……..but how do we learn from them?..but how do we learn from them?

New Tools for LearningNew Tools for Learning

APA – Accident Prevention AnalysisAPA – Accident Prevention Analysis More formal, requires full teamMore formal, requires full team Carries assurance that no administrative actions will be Carries assurance that no administrative actions will be

taken if there was no “reckless behavior”taken if there was no “reckless behavior” Written report produced that tells a storyWritten report produced that tells a story Includes recommendationsIncludes recommendations

FLA – Facilitated Learning AnalysisFLA – Facilitated Learning Analysis Less formal, may be a 3-person teamLess formal, may be a 3-person team Written report may be producedWritten report may be produced Sand Table Exercise often producedSand Table Exercise often produced Does not include recommendationsDoes not include recommendations

SAFENETSAFENET

What SAFENET IS:What SAFENET IS: An anonymous reporting system where An anonymous reporting system where

firefighters can voice safety and health concerns.firefighters can voice safety and health concerns. Documents corrective actions taken at the field Documents corrective actions taken at the field

level or provides suggested corrective actions for level or provides suggested corrective actions for higher level of action.higher level of action.

What SAFENET is NOT:What SAFENET is NOT: A forum for personal attacks/defamation.A forum for personal attacks/defamation. A mechanism to elevate “pet peeves”.A mechanism to elevate “pet peeves”. Only used for incidents that need higher level Only used for incidents that need higher level

corrective action.corrective action. Interagency criteria established for posting Interagency criteria established for posting

determination – clearly stated safety and health determination – clearly stated safety and health issue necessary for posting.issue necessary for posting.

Near Miss ReportingNear Miss Reporting

National submission decline from National submission decline from 2005:2005:

2005 -- 180 submissions2005 -- 180 submissions 2006 -- 155 submissions2006 -- 155 submissions 2007 -- down to 119 submissions2007 -- down to 119 submissions

Every report matters!!!Every report matters!!!

Firefighters Need a Single Firefighters Need a Single Handheld RadioHandheld Radio

The M16 has The M16 has been the been the standard standard infantry weapon infantry weapon for U.S. forces for U.S. forces outside NATO outside NATO since 1967.since 1967.

Medical Standards ProgramMedical Standards Program SAFENET AdministrationSAFENET Administration FireFitFireFit Six Minutes for SafetySix Minutes for Safety WFSTAR – Fire Safety Refresher Training WFSTAR – Fire Safety Refresher Training

WebsiteWebsite Red Book lead for – Ch. 7 Safety, Ch. 18 Red Book lead for – Ch. 7 Safety, Ch. 18

Reviews and Investigations, portions of Reviews and Investigations, portions of Ch. 13 Training & Quals, Ch. 15 EquipmentCh. 13 Training & Quals, Ch. 15 Equipment

NMAC coordinationNMAC coordination

SHWT UpdateSHWT Update

Energy, Nutrition, and Health Projects (MTDC): Energy, Nutrition, and Health Projects (MTDC): Wildland Firefighter Health & Safety Reports Wildland Firefighter Health & Safety Reports

(publications) (publications) Nutrition Power Point & Brochure Nutrition Power Point & Brochure Shift Food StudyShift Food Study Hydration System Field StudyHydration System Field Study Revision of Fitness & Work Capacity Revision of Fitness & Work Capacity Boot StudyBoot Study Powerline Safety Study Powerline Safety Study Requesting Seat Belt Study (human factors Requesting Seat Belt Study (human factors

perspective)perspective) Other studies: PPE (gloves, pants, shirts), chain Other studies: PPE (gloves, pants, shirts), chain

saw chaps, new Safety Zone research. saw chaps, new Safety Zone research.

SHWT UpdateSHWT Update

New - Incident Emergency Medical Task New - Incident Emergency Medical Task Group - replaces Emergency Medical Group - replaces Emergency Medical Support Group. Support Group.

Hazard Tree & Tree Felling Task GroupHazard Tree & Tree Felling Task Group Injury/Illness Module in ISUITE – input Injury/Illness Module in ISUITE – input

made by MEDL made by MEDL Updating Agency’s Administrator Guide Updating Agency’s Administrator Guide

to Critical Incident Managementto Critical Incident Management