Risk Management 2007

1. Risk Management2007

2. 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%

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

6. 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 accidents • Heart attacks are a lesser but still significant cause of federal firefighter deaths

7. 2007 Year in Review

8. 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

9. 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?

10. Who Became Entrapped

11. Where Did Entrapments Occur? • 25% in WUI situations • 75% outside the WUI

12. Level of Incident Management2007 Entrapments

13. Recommendations • Figure out ways to reduce driving exposure • Emphasize use of seat belts • Emphasize proper use of PPE • Maintain fitness programs and health screening • Firefit

14. Recommendations • Maintain emphasis on entrapment avoidance • Use case studies and STEX • Focus firefighters on operational risk assessment • But don’t develop another checklist • Engage your Incident Management Teams

15. Shifting Gears • How do we know all the information just presented? • Why should we pay attention to “near miss” events? • What are the best ways to learn from unintended outcomes?

16. Accident PyramidH.W. Heinrich - 1931

17. 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’

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

19. 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

20. Organizational Factors 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

21. 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”?

22. 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

23. 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

24. 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 reoccurrence”. James Reason

25. 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

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

27. 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 them. • Failures come as unpleasant surprises. Failures are introduced to the system only through the inherent unreliability of people. Sidney Dekker

28. 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 people’s assessments and actions would have made sense at the time, given the circumstances that surrounded them Sidney Dekker

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

30. What’s 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?

31. 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. --Dekker • We match our hindsight of people’s performance with a procedure or collection of rules: • People’s behavior was not in accordance with standard operating procedures that were found to be applicable to the situation afterwards.

32. But we don’t 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 people’s behavior against the investigator’s 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

33. What about “loss of situation awareness”? • If you lose situation awareness, what replaces it? • There is no such thing as a mental vacuum. • The only way to “lose awareness” is to become unconscious. • So….people didn’t lose awareness, rather the awareness that they had differed from reality. • Why?????

34. 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 by…adapting under pressure and acting under uncertainty. Sidney Dekker

35. 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

36. So What Is Doctrine? Doctrine is the expression of fundamental concepts and principles that guide planning and action. • 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 mission.

37. 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.

38. 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.

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

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

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

42. Learning and punishment don’t mix • “A system cannot learn from failure and punish supposedly responsible individuals or groups at the same time.” --Sidney Dekker

43. True Safety Lies in Learning • Learning is about seeing failure as part of a system. • Learning is about countermeasures that remove error-producing conditions so there won’t be a next time. • Learning is about increasing the flow of safety-related information. • Learning is about…the continuous improvement that comes from firmly integrating the terrible event in what the system knows about itself.

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

45. 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

46. SAFENET • What SAFENET IS: • 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.

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

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

49. 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

50. SHWT Update • Energy, Nutrition, and Health Projects (MTDC): • Wildland Firefighter Health & Safety Reports (publications) • 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 perspective) • Other studies: PPE (gloves, pants, shirts), chain saw chaps, new Safety Zone research.