The Human Factors Analysis and Classification System—HFACS Cover
and Documentation
Introduction
1. Unsafe Acts
2. Preconditions
for Unsafe Acts
3. Unsafe Supervision
4. Organizational
Influences
Conclusion
References
HFACS and Wildland Fatality Investigations
Hugh Carson wrote this
article a few days after the Cramer Fire
Bill Gabbert wrote this article following the release of the Yarnell Hill Fire ADOSH report
A Roadmap to a Just Culture:
Enhancing the Safety Environment
Cover
and Contents
Forward by James Reason
Executive Summary
1. Introduction
2. Definitions and Principles of a Just Culture
3. Creating a Just Culture
4. Case Studies
5. References
Appendix A. Reporting Systems
Appendix B. Constraints to a Just Reporting Culture
Appendix C. Different Perspectives
Appendix D. Glossary of Acronyms
Appendix E. Report Feedback Form
Rainbow Springs Fire, 1984 — Incident Commander Narration
Introduction
Years Prior
April 25th
Fire Narrative
Lessons Learned
Conclusion
Tools to Identify Lessons Learned
An FAA website presents 3
tools to identify lessons learned from accidents. The site also
includes an animated
illustration of a slightly different 'Swiss-cheese' model called "defenses-in-depth."
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RAINBOW SPRINGS FIRE
INCIDENT COMMANDER NARRATION
Given February 1997 for use in the Fatality Fire Case Study Training Course
April 25th
As usual, we came to work on the Morning of April 25, 1984 with fire
being the last thing on our minds. It had been decided about a week earlier
that our spring fire season was over and the fire staff officer had released
the air tanker that was under contract for the forest. About 4 days earlier
we had received over an inch of rainfall that helped disguise the extreme
fire weather that would be experienced later that day.
While we were not thinking fire, none of us expected April 25th to be just
another day. We had very serious personnel problems. One of our primary technicians
was under investigation for serious ethic and conduct violations. The overall
morale was extremely low. We had planned a district meeting during that afternoon
to discuss our problems and identify ways to come together as a district.
Sometime during that morning the District Ranger and I traveled to the field
to look at some timber marking in progress. At about 1100 hours I noticed
the wind was very strong from the southeast. I remember thinking for a moment
that the fire danger must still be very high because in addition to the wind,
there was not as much green vegetation as one would expect that late in the
spring season. We returned to the district office just before noon to make
final preparations for our district meeting that was scheduled for the afternoon.
At about 1330 hours the, aerial observer reported a fire in the Rainbow Springs
area and described the fire as spreading very rapidly. Once he gave the legal
description, I realized the fire must be burning in an active timber sale
with heavy pine slash and probably on the steep south facing slope of Dallas
Mountain.
As unprepared as we were, we wasted little time departing to the fire. The
ORA, who had been on the district less than one year asked me to accompany
him to the fire. As soon as we cleared the office parking lot we could see
a very large column of black smoke that appeared to be in the vicinity of
Rainbow Springs.
Travel time from the office to the fire was about 15 minutes. What I remember
most about that trip was the ORA’s suggestion that no matter what happens,
things cannot get any worse. My reply was “Oh hell yes they can too”.
I was thinking about our young inexperienced people and was concerned about
their mental state due to the aforesaid problems. I was also thinking about
our new tractor operator that to my knowledge would be operating his first
fire. I did not know for sure who would be IC but felt I would be asked to
assume that responsibility once we reached the fire. Therefore, being familiar
with the terrain and fuel conditions, I was already thinking about a plan
of action.
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