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
Introduction
During the past year I received word that I may be asked to participate
in a fire safety training program that deals with past wildfires involving
fatalities or serious injuries to firefighters. As Incident Commander
on the Rainbow Springs Fire that started around noon on April 25, 1984
and
claimed the lives of two Forest Service employees, I assumed my role
would be to stand in front of a video camera and talk about the many things
that
went wrong from initial attack until the tragic accident over 2 hours
later. My initial response was that I would help reconstruct the events
that ultimately
caused the two fatalities. However, with the objective of using the
Rainbow Springs experience to help prevent a similar disaster, I felt
very strongly
that what happened on that tragic day is not nearly as important as
what happened in the months and even years leading up to that day.
“If
I am able to provide a clear picture of our actions you will notice
that to some degree we violated all of the 10 Standard Fire Fighting
Orders. If there had been a Standard Order Number 11, there is every
reason to
believe it would have been violated too. ” |
I am not even sure what can be learned by discussing our action from the
time the fire was reported at 1330 hours to the time of the accident around
1630 hours on April 25, 1984. If I am able to provide a clear picture of our
actions you will notice that to some degree we violated all of the 10 Standard
Fire Fighting Orders. If there had been a Standard Order Number 11, there
is every reason to believe it would have been violated too. Experts were dumbfounded
because the 10 Standard Fire Fighting Orders are taught in basic firefighting
courses and some of us at the Rainbow Springs Incident even had them glued
to our hardhats. So what was the problem? There may not be a simple answer
but a honest and candid discussion of the low priority the Mena Ranger District
gave to fire management that resulted in a total lack of fire readiness should
provide clues to why we performed so poorly throughout the course of the afternoon
on that tragic day.
<<< continue
reading Rainbow Springs Fire, years prior >>>
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