Tuesday, March 24, 2015

BLM FLT Participates in the Devil's Den Staff Ride

Helmet, ax, and drip torch at Devil's Den
Devil's Den Staff Ride
BLM National Fire Leadership Team 
Spring Meeting
April 16, 2014
Oak City, Utah


On August 17, 2006, a Bureau of Land Management employee from Utah sustained a line-of-duty death on the Devil's Den fire that was located on the Fishlake National Forest. The fire was located approximately 1.5 mile east of Oak City, Utah. The fire started on August 15, and had grown to more than 20 acres by the morning of August 16. By the end of August 16, the fire had grown to more than 90 acres but was 75% contained.

On the morning of August 17, the Assistant Fire Management Office (AFMO) who was also the Zone Duty Officer visited the fire and took a flight of the fire with the Incident Commander (IC) and IC (Trainee) at approximately 1230 hours. They landed at an established helispot and had a conversation on the tactics and plan for the day. At approximately 1300 hours, the AFMO walked down from the helispot into the canyon where the fire was located to scout the line. Shortly after departing the helispot, the AFMO requested a helicopter for bucket support on some spot fires that developed in the canyon and outside the control lines. At approximately 1350 hours, the IC noticed that fire activity had started to pick up and black smoke coming from down drainage from the AFMO’s position in the canyon. The IC radioed the AFMO and told him of the activity and that he needed to get out of there. Shortly thereafter, the IC told the AFMO to drop his pack and run. Radio communication was lost with the AFMO and repeated radio calls went unanswered. At approximately 1700 hours the AFMO’s body was located and official notification of the fatality were made to the District Ranger at 1735 hours.

*** Reference the Devil's Den Accident Investigation Report for the report in its entirety. ***

In the fall of 2013, Rex McKnight, co-chair of the BLM National Fire Leadership Team (FLT), asked BLM Utah, who was hosting the spring 2014 FLT meeting to facilitate a staff ride for the FLT. The Devil's Den fire was selected and a staff ride facilitated on April 16, 2014.

The Staff Ride included representation from all BLM states, along with representation from the National Interagency Fire Center (NIFC), the BLM Acting Assistant Director for Fire and Aviation and staff from BLM Utah.

The Staff Ride

The staff ride began in Salt Lake City with a bus ride to the Devil's Den Trail Head located in the Oak City Canyon, approximately 1.5 mile east of Oak City proper. During the bus ride, the Devil's Den “Lessons Learned Center” video was shown along with a Google Earth virtual tour and group discussion on objectives and goals of the staff ride. The goal of the staff ride was twofold, first to put the FLT in the boots of the AFMO and see what decisions they would have made and how their decision would have differed. Second, what decisions or influence could the FLT make in their current positions to help mitigate or prevent a similar accident from occurring anywhere else in the BLM.

*** Reference the Devil's Den Staff Ride packet that was provided by BLM Utah ***

During the staff ride the following topics were brought up and discussed among the FLT and BLM Utah facilitators:
  • Setting the Stage
    • There had been numerous fires within the fire zone and this was just another fire. By the end of the Initial Attack (IA) period, it was 75% contained. Much of the Richfield Fire Staff had started to go back to school and even with the loss of personnel, camaraderie was at a seasonal high.
    • What if anything, could have been a warning sign that things were developing or foreshadowing a fatality was about to occur?
      • The Zone Fire Management Officer (FMO) had been gone for a majority of the season due to participation in Incident Management Teams (IMTs).
      • This was just another Red Flag Warning day, just like it had been the previous days.
      • There were several other Type 3 and Type 2 fires going on, and they had started to wrap up operations as objectives and control measures were being met.
    • Providing a plan and creating an atmosphere as well as promoting a culture where people can speak up when they feel uncomfortable.
    • Having a supervisor or crew superintendent ask subordinates what is the plan, do they support the plan, and is the supervisor missing anything or does everyone have the full picture (“The Gut Check").
  • Normalization of Risk
    • All firefighters have slides based on previous experiences where there might have been close calls but had a positive outcome. (Cutting through the green hundreds of times). The current times and conditions need to be emphasized to firefighters as it relates to current day conditions (budgets, ecosystem conditions, workforce plans, reduction in available resources). Evaluating each situation and making sure the plan of action is still valid at all steps along the implementation process.
    • From a State Fire Management Officer (SFMO) perspective, the normalization of risk easily could be the reduction of budgets and workforce planning. Decisions that are made at the SFMO level changes or impacts the number of resources that boots on the ground have to depend on or utilize in suppression actions. This alters slides that firefighters have from previous experience but don’t validate accurate conditions based on budgets and workforce plans.
  • Being Resilient
    • Managers from NIFC to SFMOs to Agency Administrators should be providing letters of expectations. This would include the importance of the Risk Management Process regarding tactics and the current fire situation. It is important for up-and-comers as well as more experienced firefighters to understand that the number of resource in the system is significantly reduced from previous years (heavy airankers, Type 2 crews, etc.) and Nationally, we are going to see higher preparedness levels earlier and more frequent.
    • Pressing upon folks to make tactical plans on fires and establishing future plans on reduced number of resources, increased fire behavior, dramatic changes in vegetation and ecosystems. This will help programs be resilient in dealing with the changing environment if the expectations and future planning is inline or consistent with the real-life conditions today.
  • Resource Utilization
    • The Bureau and SFMOs/DFMOs need to do a better job sharing and utilizing the right resources for the need. This includes sharing across state and geographic boundaries; we need to look for efficiencies within our individual states that will help the Bureau fire program as a whole.
  • Feedback
    • Through expectations and further development of a highly reliable organizational (HRO) culture within the BLM fire program and even across BLM functional boundaries; a better job needs to occur where employees are empowered and have the ability to provide feedback and input into the decision process (also mentioned above).
    • Providing additional opportunities for our employees to succeed by promoting and further development of leadership curriculum that emphasizes the importance of the leadership but also the follower roles.
  • Defining Success
    • The definition of success is dependent on individual situations but the consensus of the group was success could be defined and measured by the development and promotion of core values within the fire program nationally.
      • The values need to be readable, easily understood and make sense to the up-and-coming firefighter.
    • We will continue to mitigate risk, prevent injuries and fatalities; but we are in an inherently risky profession when injuries and fatalities will occur. Discussions were had that during and after a serious injury or fatality we must continue to support our employees and their families to help our employees and agency be a resilient organization.
    • Having plans on how the Bureau, states and districts are going to handle these types of situations before they occur is key to the success of how employees and their families can be supported.
    • How and what type of help is needed when a serious accident or fatality occurs.
Take-home Messages from BLM Fire and Aviation Leadership
  • It was very rewarding for me to participate on this staff ride with my peers and our leadership from NIFC. I feel that far too often, we get bogged down with the demands of the job and risk losing sight of the firefighters on the ground who are executing our decisions.
  • Over the course of the day, I was reminded of the importance of being mentally and physically fit for duty. As a State Fire Management Officer, I have the responsibility of being a good role model and maintaining a healthy work-life balance.
  • We as a leadership team spend too much time staring at each other in conference rooms. This staff ride gave us an opportunity to interact in a different environment and see one another in a different light.
  • This staff ride gave fire leadership an opportunity to meet and interact with District and Forest fire staff whom we may never have met otherwise.
  • This staff ride gave me an appreciation for a piece of ground in a part of the country I hadn’t been in for a long while. I have a new appreciation for some of the challenges facing our fire management folks at the local level.
  • To have the opportunity to have first hand, in living color perspective from our facilitators was irreplaceable. To do it among a group of leaders asking the operator questions, gave me multiple perspectives that I would never be able to obtain in my lifetime, as historical assay was occurring before our eyes!
  • To use the senses - hike makes us walk in their shoes, sweating and breathing requires us to speak to the fitness or health of individuals (let alone ourselves), seeing the terrain, navigating a route, viewing the distant influences of the geography that may have or have not influenced operational decisions, smells and sounds ............. all invaluable and unachievable in a meeting room or a lessons learned digital presentation.
The Staff Ride Itself
  • A "powerful" experience, to be able to walk the same terrain/topography Spencer walked + attempt to process what was running through his head + what I would have done is worth a 1000 Powerpoint presentations.
  • The HRO wildland fire operations tenet of being "mindful," having our "heads-in the game," being "in the moment"... Not fixating on the past, or ruminating about the future... Rather than "react" focus on "responding."
  • We can't, nor should we try to multi-task in our business... Duty Officer, AFMO, directing bucket drops.
The FLT:
  • Excellent logistics/planning (Chris Delany, LJ Brown), EMT support, Guides/Stations (Well done, Utah BLM)
  • Some of the best FLT communications I've seen (idea sharing, problem solving)... To and from the site on the bus. Nice job.
  • Great feedback from non-FLT BLM fire folks (Utah BLM FOSs, AFMOs) in West Desert District... Impressed we (the FLT) took a day out of our schedules to "study" a fatality, focus on safety/risk management... A good message to send that we take this seriously.
  • Todd Richardson "rules"... To make that hike so soon after knee surgery (grit/determination/perseverance)...
  • Reattach with the field operations. It is easy to sit in the ivory tower and make uninformed comments on incidents and staff.
  • SFMOs/SO must be mindful of vacancies in the field and subsequent "Actings" to ensure span of control and situational awareness is maintained at the operational/field level.
  • Order leadership when necessary!
  • A great reminder to the field and SO of over-engagement of DOs to fire operations. They must maintain 30K level of situation and not commit to an incident or individual district.
  • Flip-side is, is the importance of DOs to maintain engagement/awareness on all incidents and not assume all is going well; i.e., complacency (especially at the SO level).
  • I also have created a new watch for myself. Watch out when "subordinates in the office setting are your superiors and supervisors on the fireline." This should not be a problem, but continues to haunt me about this incident.
  • Be prepared for serious accidents and have updated Emergency Protocols and Death in the Line of Duty Procedures.
  • Senior Management (State and National) needs to play a bigger role in the lessons learned and/or recommendations after these serious accidents. Often times we can pass the buck down to the districts/unit and tell them what they need to fix, and we are negligent in identifying recurring mistakes at our level.
  • The Devil's Den staff ride was a great experience. It gave the FLT a chance to break the norm and not only team build but take back some important lessons learned on human dynamics. In the fire world, we are in a constant learning environment and the FLT needs to continue to champion the concept of continually learning from the past so we can better the future for all of our personnel. I think this staff ride and hopefully future staff rides like this will solidify that commitment. This staff ride gave me as a State FMO the opportunity to go back to my state and sit down preseason with our district fire personnel and review this incident and discuss human factors within their districts.
  • The Devil's Den staff ride with the FLT was an excellent opportunity for the group to grow as a team and to prepare us for the fire season. We must continue to provide learning opportunities, as activities like this to grow better leaders, increase our awareness of past so we don't continue to make the same mistakes over again, and to help us define and refine success in the BLM fire program.
  • I took away from this staff ride that focusing on the big picture is important for fire managers at the field and state office levels. Focusing on one specific incident and not listening to an incident commander are a deadly combination. To ask for help is OK and for SFMOs to provide help where help is needed. This requires all of us to be diligent in touching bases with the field on a regular basis.
A special thanks to Kyle Cowan (BLM-WY) and Chris Delaney (BLM-UT) for capturing this experience, for the BLM FLTs permission to reprint their experiences and comments in this blog, and for the staff ride SMEs for being a part of this transformational experience.

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