Human factors critical 20 years after South Canyon firefighting tragedy in Colorado

Human factors critical 20 years after South Canyon firefighting tragedy in Colorado

04 January 2014

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USA — Flames crackling mere millimeters behind him, Eric Hipke clambered up the last steep stretch of a rugged mountainside engulfed by roiling fire.

Hipke was panting hard when he screamed and hurled himself over the ridge.

He made it with five seconds to spare, investigators concluded later.

The blaze seared the back of Hipke’s neck, arms, legs and the hands cupped over his ears.

The worst agony, though, was learning that 14 fellow firefighters perished behind him on Storm King Mountain on July 6, 1994, in Colorado’s South Canyon fire. Nearly 20 years later, Hipke’s burns have healed. His sorrow, however, persists.

Wildfire deaths of this magnitude had not occurred for 45 years, not since Montana’s Mann Gulch fire killed 12 smokejumpers and a forest ranger on Aug. 5, 1949.

The Colorado catastrophe signaled the need for critical changes, and many have been made.

The mountain today is studded with marble crosses, each laden with personal mementos, on the spots where the four women and 10 men died.

The Granite Mountain Hotshots of Prescott, Ariz., made the pilgrimage there two years ago to pay their respects, recalled Darrell Willis, wildland division chief for the Prescott Fire Department.

“We hiked Storm King Mountain with this (20-member hotshot) crew, and we all said, ‘This will never happen to us.’ ”

All but one of those hotshots died this past June 30 on the Yarnell Hill fire in Arizona, where shifting winds, canyon topography and an apparent lack of situational awareness eerily echoed the South Canyon tragedy.

The 19 deaths in Arizona shocked firefighters and civilians alike. They occurred 19 years after South Canyon.

“I never thought we’d wipe out a whole crew,” said Randy Skelton, deputy fire staff officer on the Payette National Forest.

In all, 34 people died this year while fighting wildfires, the worst count in almost 20 years.

Despite all the refinements to wildfire fighting, the death toll is up.

Two factors are spiking the dangers exponentially:

Climate change is producing abundant lightning storms and severe droughts resulting in landscapes of dried cheatgrass, brush, beetle-killed trees and other highly flammable fuels. Fire seasons now last up to 10 months rather than five or six.

“I was seeing fire behavior this year that I hadn’t seen in a while,” Josh Brinkley said in September while standing on Storm King Mountain, where his brother Levi was killed. “Everything was so dry.”

“The PIG (probability of ignition) in a normal year is 80 percent. This year, as early as 9 a.m., it was 100 percent all season long. I talked to old-timers who had never seen it that dry for years,” said Josh Brinkley, a Twin Falls-based supervisory wildland fire operations specialist with the U.S. Bureau of Land Management.

Simultaneously, more and more homes are being erected in the wildland-urban interface – most without fire-retardant materials much less any fire-defensible space.

The trend underscores a lack of responsibility by local governments and property owners, said Larry Edwards, a 1970s hotshot in California, Oregon and New Mexico who landed in Helena in 1989 as a superintendent and retired in 2004.

“Personal rights come with responsibilities. In Australia, homes are built to be defensible. They don’t put firefighters in there to save homes,” Edwards said. “They understand that they’re living with wildfire, and we don’t have that understanding here.”

While none of this bodes well for people fighting wildfires, some deaths may be inevitable in a volatile environment where Mother Nature rules in random fashion, fire managers acknowledge.

“You can’t apply an OSHA model to what we do. It’s not a factory floor,” said Jim Cook, who recently retired after 37 years in fire service, including 18 years as a hotshot crew superintendent and 14 years as training projects coordinator for the U.S. Forest Service at the National Interagency Fire Center in Boise.

Still, with dozens killed in one year and global warming and wilderness construction ramping up, Cook and his colleagues across the West know something must be done.

Experts interviewed over the past six months cited one primary key to wildfire deaths: human factors.

Psychologist Ted Putnam is the “father of human factors,” said Hipke, who makes safety training videos in Boise for the Wildfire Safety Training Annual Renewal.

Putnam was on the investigative review team for the South Canyon fire, but refused to sign the official report because he found it inaccurate and incomplete, ignoring too many pertinent human factors.

“I think it was honorable that Ted Putnam didn’t sign that report. I don’t think it told the whole story,” said Joe Brinkley, manager of the McCall Smokejumper Base, brother of Josh Brinkley and a triplet brother of Levi, who died in the fire.

“God bless (Putnam),” said John MacLean, author of “Fire on the Mountain” and three other nonfiction books on wildfires. “He’s done a great, great service on human factors.”

Putnam joined the U.S. Forest Service in 1963 and was a smokejumper from 1966 to 1976, with three years as a squad leader.

On July 17, 1976, he fought the Battlement Creek fire, which killed three men – from Idaho, Arizona and Wisconsin – about 40 miles west of Storm King Mountain. A fourth man survived; he had lain face-down, and the fire passed over him.

Putnam warned other bosses 15 minutes and again three minutes before the fire roared up the hill. One victim’s clothes were undamaged, another’s were burnt off, and the third victim and the survivor’s clothes were burned across the back only.

The discrepancies intrigued Putnam, who moved to the Missoula Technology and Development Center at once to help research and design better protective fire gear. He studied statistics and mathematics for six years while working on his doctorate in research psychology.

A workshop he held on human factors on the South Canyon fire led to deeper scrutiny of human factors inherent in decision-making, situational awareness and leadership and a push by Putnam for a national study on firefighter safety, launched a month later.

While earlier investigative reports cited the facts of people’s actions on wildfires, Putnam consistently pursues the “why” behind those actions.

In the chaos, confusion and frenzy that arise when battling a wildfire, people develop tunnel vision.

They need to step back, cooly gaze across the landscape and mindfully note all the changes occurring. Instead, they cling to whatever idea or plan they already made, shutting out new developments, said Putnam, a Missoula resident who winters in Prescott.

“Stress, fear and panic predictably lead to the collapse of clear thinking and organizational structure,” Putnam wrote in a 1995 paper for the MTDC.

“While these psychological and social processes have been well studied by the military and the aircraft industry, the wildland fire community has not supported similar research for the fireline. The fatal wildland fire entrapments of recent memory have a tragic common denominator: human error.”

One such error was a dispatcher’s failure to transmit to firefighters a red-flag warning of a cold front bringing high winds to Storm King Mountain.

Chris Cuoco, a National Weather Service meteorologist in Grand Junction, Colo., had worked nonstop to ensure that the latest weather updates got to the fire crews.

He wept when he learned that they never received that news.

The military trains its people in mindfulness and situational awareness, said Cuoco, an Air Force veteran.

“They teach pilots this, airline pilots in particular. They have to take in a great deal of information very fast. They put them through hell in training. It reinforces … how stress and exhaustion can affect the brain,” Cuoco said.

Putnam is “pretty academic, but human factors are a huge part of what’s going on out there,” said Winslow Robertson, who held the No. 2 position for the BLM in Grand Junction when the South Canyon fire erupted.

“I’m a survivor, too, and I rehash this thing over and over and over. We use the word ‘mindfulness’ out there; I’m a big believer in that,” he said during a Sept. 27 interview in Palisade, Colo. “We want everybody to come home at night; we want everybody to stay safe. We want mindfulness, a hard word to describe.”

“Mindfulness,” said Hipke, “in whatever terms, is just being aware, being in the now. You get on autopilot.”


The question is how to inject mindfulness and situational awareness into a culture of tough, brave, can-do workaholics – the wildfire crews and their leaders.

Putnam’s approach draws some skepticism. The longtime student of eastern Zen meditation swears by that practice to gain control of one’s mind.

Putnam held meditation workshops with wildland firefighters and, by all reports, many found it useful. The psychologist himself tries to meditate twice a day. When he doesn’t, his wife Gay gently remonstrates him: “Ted, you’ve gone off your meditation.”

Edwards, the old-school hotshot who retired in Helena, took some Putnam workshops and modified the approach for his hotshot crews.

“We would do a breathing exercise to clear all the clutter out of your head and have a blank slate so, when you get the briefing, you could get it in (your head),” he said. “No questions were to be asked. Just be there and listen. Then we would go into a visualization period – put yourself in the situation described, the weather, what to expect. Then we would open it up to questions.”

On the fire front, “whenever we had a change of plan, the protocol was: We’d go through the whole process again and recognize things had changed.

“We had a really good safety record, and we had a really good crew, too,” Edwards said. “I think people felt they were part of something. … Smart people on the crew gave me feedback. I’d ask, ‘Did it help?’ ‘Yeah, it helped a lot.’ ”

Meditation won’t work “for some ex-cowboy who becomes a firefighter in Montana,” Cuoco said. “This is physiological, this is science, this is how the body reacts. They’re now realizing they need to give people training. The only way to learn to react under stress is to put them under stress and show them how that thinking changes. It’s not conscious. It has nothing to do with Eastern meditation.”

Many fire leaders endorse Putnam’s concept but recommend it be pitched with more emphasis on visualization and mindfulness to make it palatable to the fire community.

“I think Ted’s onto something,” Cook said. “There are all different ways mindfulness could be integrated (into training).”

It already is a central focus in much wildfire leadership training. And that training has come a long way since South Canyon.

Coming Thursday: How has wildland firefighter training changed since Storm King Mountain?

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