Thread by @JimWhittington

A few words on investigations: whenever you have a serious accident or fatalities, there will be an investigation and sometimes multiple ones—and they may not all agree on the issues. 1/ #DATM

That was the case here as the AZ Dept of Forestry and AZ OSHA issued completely different reports. The former reflected the current thinking in the wildland fire community, which was to get away from looking for cause and blame. 2/ #DATM

Whenever you have an investigation, you are operating in hindsight and it is impossible to recreate the stresses and time compression decision-makers were operating under at the time. Simply, before the accident, the outcome is unknown. Afterwards, it is known. 3/ #DATM

Before, things are dynamic, complex, uncertain, and time-sensitive. After, we simplify and the process becomes linear and static as we choose what to focus on in pursuit of the outcome and “cause.” 4/ #DATM

If you look at early wildland fatality investigative reports, you see they recognize the problem of hindsight bias. Sometime in the 1950s-early 1960s, there’s a change in the reports as the word “negligence” starts appearing and they take on a more legal tone. 5/ #DATM

During the 1990s and early 2000s, there were several notable investigations that levelled charges at individual firefighters for their decision-making. The AZ OSHA report followed that pattern of looking for cause and blame. 6/ #DATM

That report was full of phrases like “should have,” could have,” and “failed to.” In contrast, the other report looked at conditions and considered that Granite Mountain was a well-trained and experienced crew. 7/ #DATM

If they made decisions that led to a bad outcome, wouldn’t others of similar training and experience make similar decisions under similar circumstances? We must seek to identify conditions that push decisions that result in bad outcomes. 8/ #DATM

That’s part of a learning culture. We get nowhere blaming individuals and pretending that a new policy will fix things. We need to understand the totality of the incident from the individuals on the ground making decisions to the org and policies that influence them. 9/ #DATM

James Reason and Sidney Dekker have both written books that influenced the wildland fire community. They look at the folly of “human error” and placing blame. Instead, they focus on systems. 10/ #DATM

Daniel Kahneman’s book “Thinking Fast and Slow” has nothing to do with emergency response, but everything to do with emergency response. It delves into how we think and process information, including the unexpected. 11/ #DATM

“Managing the Unexpected” by Weick and Sutcliffe talks about high reliability organizations and learning cultures. 12/ #DATM

Finally, the Wildfire Lessons Learned Center has a great cache of documents and reports from fatality fires and others influential incidents. It’s a great resource for many other bits of emergency management too. 13/13 #DATM
wildfirelessons.net/home