Friday, August 22, 2014

Swiss-Cheese Model (SCM) and Margin

Concept of MarginJames Reasons Swiss Cheese Model
Authors: Ivan Pupulidy, Director and Matt Carroll, Human Factors Specialist; USDA Forest Service Office of Learning

Comparing the Swiss Cheese Model (SCM) and Margin is not a direct “apples to apples” comparison. The SCM was introduced to the wildland fire community through the L-380 curriculum and is intended primarily, as an “ innovative framework for thinking about human error…[that] scrutinizes all levels in an organization when looking for the causes of human error” (Mission-Centered Solutions Inc., 2007, p. 55). It was designed to pinpoint the causes of an accident or error by describing the holes in defenses that, when aligned through multiple levels, create an error chain. Margin, is focused on the influence that conditions have on decisions and actions; it does not attempt to describe a linear causal relationship among conditions at various levels, rather it describes the collective influence of these conditions. The focus can then shift from cause to understanding the capacity to cope with uncertainty, error and surprise. SCM is intended to make sense of an accident after it happens, whereas margin, while it can be used in accident analysis, is designed to help users describe the potential for the system to do harm before an accident occurs.

While these differences may seem academic they are not, they have a significant effect on practical application and learning. In accident investigation for example the models we choose can influence what we look for and in turn influence what we ‘see’, or determine what is relevant to the investigation. Erik Hollnagel warns us that a model can bias the perspective of analysts when he describes the, “What –You-Look-For-Is-What-You-Find (WYLFIWYF)” principle (Lundberg, et al., 2009). This principle suggests that the model used for a review of an event will determine what you find and more importantly for us, what you fix[1]. This in turn affects what is learned and how that learning is applied to improve system performance. In light of this we should focus on how these models determine what we ‘see’ and therefore what we fix. We should ask what it is that we want to do, “Do we simply want to find and fix defenses (i.e., plugging hole, fixing/adding barriers) or do we want to find ways to increase the system’s capacity to weather error/surprise and uncertainty without consequence?”

SCM opened our eyes to the influence of upstream failures or holes in defenses, but is limited in that it is best used after the fact and it focuses on error or absence (looks for holes). By drawing an error chain you lose the ability to talk about the influence (good or bad) of other conditions throughout the system. Calling something an error, weakness, omission, failure (Mission-Centered Solutions Inc., 2007, p. 56) (Reason, 1990) artificially simplifies the nature of conditions; because every error was likely a solution to, or influenced by, something else. SCM results in plugging the detected holes in the failed barrier to avoid some downstream event. This process is designed to make systemic corrections at a managerial level (leadership adds more barriers or defenses, e.g. rules, regulations, policy, procedures or PPE). What is suggested is only part of the issue of prevention. SCM suggests the responsibility of creating safety is done up stream in the organizational leadership.

Margin opens the discussion to include the role of workers in the creation of safety. It provides a means of describing and detecting the capacity of a system by focusing on the margin available for action. After an accident conditions play a different role in the margin concept. They are intended to mapped or recognized as influences to decisions and actions. Describing these conditions places actions and decisions in context and allows us to move beyond fixes.

For an introduction to the concept of Margin, please refer to the following short video:

Works Cited
Lundberg, J., Rollenhagen, C. & Hollnagel, E., 2009. What-You-Look-For-Is-What-You-Find - The consequences of underlying accident models in eight accident investigation manuals. Safety Science, Volume 47, pp. 1297-1311.

Mission-Centered Solutions Inc., 2007. Fireline Leadership (L-380). Missoula (MT): Mission-Centered Solutions Inc..

Reason, J., 1990. The Contribution of Latent Human Failures to the Breakdown of Complex Systems. Philisophical Transactions of the Royal Society of London. Series B, Biological, 12 April, 327(1241), pp. 475-484.

[1] Based on the corollary principle of “What-You-Find-Is-What-You-Fix” (Lundberg, Rollenhagen, & Hollnagel, 2009).

Thursday, August 21, 2014


Rocky Mountain Region Bulletin - Blackwater Fire 1937
On August 21, 1937, the tragic Blackwater Fire caused the death of 15 firefighters, burning approximately 1,700 acres of Shoshone National Forest land, near Cody, Wyoming.

An electrical storm occurred in the general vicinity of Blackwater Creek on Wednesday, August 18th causing a fire, which was not detected until August 20th. At the time of detection, the fire appeared to be only 2 acres in size and was located in the drainage bottom. By the evening of Friday, August 20th, the fire had grown to approximately 200 acres and there were 58 men and 7 overhead constructing fireline in an orderly manner and with good speed. Early Saturday morning the man-power was about evenly distributed along the two main flanks of the fire. As more crews arrived and line construction advanced to the east on the hottest section of fireline, a blowup of the fire occurred at approximately 1545 caused by the combination of an undiscovered "spot" and the passage of a dry cold front. In this conflagration, 9 deaths occurred directly. Six additional men were so badly burned that death ensued, and 38 additional men suffered injuries.
Blackwater Fire 1937

Preliminary reports on this lightning fire showed that initial action was vigorous; quite remarkably so, considering the remote location of the fire and that the Shoshone National Forest was considered a low-danger forest. The forest didn't even have lookout stations. Up until 1939, the Blackwater Fire was the largest loss of life from a single national forest fire since 1910.

The Blackwater Fire was the first fatality fire to have significant investigation and study of the event done immediately after the tragedy. This analysis of the fire eventually led to the development of the smokejumper program, a management action to address the time delay problems encountered for crews responding to the fire.

In memory of
~ Alfred G. Clayton, Ranger
~ James T. Saban, Technical Foreman
~ Rex A. Hale, Jr. Assistant to the Technician
~ Paul E. Tyrrell, Jr. Forester
~ Billy Lea, Bureau of Public Roads Crewman
~ Clyde Allen
~ Roy Bevins
~ Ambrogio Garcia
~ John B Gerdes
~ Will C. Griffith
~ Mack T. Mayabb
~ George Rodgers
~ Ernest Seelke
~ Rubin Sherry William Whitlock

Honor through learning and visit the Staff Ride Library.


Food for Thought - Seeds of Hope

"Even in obstacles, a leader finds the seeds of hope." ~ Steve Gutzler

"Even in obstacles, a leader finds the seeds of hope." ~ Steve Gutzler

Tuesday, August 19, 2014

Are You Providing a Circle of Safety for Your Team?

Simon Sinek's circle of safety
"When people feel safe and protected by the leadershp in the organization, the natural reaction is to trust and cooperate." ~ Simon Sinek

Video Highlights
  • Deep emotion such as compassion says volumes about a leader.
    • Watch CBS's news story about Congressional Medal of Honor Captain William Swenson and his leadership during and after the incident (future blog topic).

  • The leadership environment can give each of us the capacity to do remarkable things. 
  • "Better" people have a deep sense of trust and cooperation.
  • Trust and cooperation are feelings that are found within our circle of safety.
    • The leader sets the tone. When a leader makes a choice to put the safety and lives of the people inside the organization first, to sacrifice their comfort and sacrifice the tangible so the people remain and feel safe, remarkable things happen.
    • If the conditions are wrong, we're forced to spend our own time and energy to protect ourselves from each other and that in turn weakens the organization. 
  • Leadership is a choice. It is not a rank.
"Leadership is a choice. It is not a rank." ~ Simon Sinek

Monday, August 18, 2014

Food for Thought - Danger & Opportunity

"Whenever there is danger, there lurks opportunity; whenever there is opportunity, there lurks danger." ~ Earl Nightingale

"Whenever there is danger, there lurks opportunity; whenever there is opportunity, there lurks danger." ~ Earl Nightingale

Friday, August 15, 2014

Rocky Mountain National Park (CO) Students, Alpine Hotshots Form Bond Through Fire Training Program

Sayings like these are more than just words in the world of firefighting: “Punctuality shows respect,” “Train like you fight,” “Crew cohesion is important.” They are life lessons that students from an alternative residential high school in Estes Park, Colorado, learned during a five-week class on wildland fire.

Simply called “Fire!,” the program, now in its second year, linked six students from Eagle Rock school with Alpine Hotshots and ecologists from Rocky Mountain National Park and the Continental Divide Research Learning Center.

An existing relationship between the school, the park and hotshot crew sparked the idea for the “Fire!” program. An Eagle Rock student has been a member of the Alpine Hotshots for the past four fire seasons. In May 2011, Rafael Mcleod graduated before joining the team. Vidal Carrillo became a hotshot in 2012.

Carrillo continues to work on the seasonal crew while now working on his undergraduate degree at Colorado State University. This enthusiasm is part of what ignited the “Fire!” program. Ben Baldwin, ecologist at the learning center, and Prul Cerda, Alpine Hotshot superintendent, discussed opportunities with Eagle Rock School when they came up with the idea for the pilot program.

“After Vidal and Rafael’s success as members of the hotshot crew, we knew several kids were interested in wildland fire,” Cerda said. “Ben and I decided we needed to build on that, partly as an opportunity for diversity recruiting.”

Baldwin approached Eagle Rock School with the idea to develop the pilot course for citizen fire science, similar to other citizen science programs offered through the learning center. While the initial idea was to put the students through a 40-hour basic wildland fire course in order to certify them as wildland firefighters, Cerda and Baldwin quickly realized lectures were not going to be the best learning environment for these students.

“These are students who were not going to get much out of sitting in the classroom,” Cerda said. “They are used to more experiential learning through a hands-on approach. That’s also why we incorporated the physical training standards as part of the curriculum.”

This year, learning center staff member Holly Nickel used her expertise in education and curriculum development to refine and develop materials for this course.

“Four of the key principles in fire—safety, physical training, fire ecology, and fire suppression—were the goals of the new fire curriculum,” Nickel said.

Instructors challenged students to memorize and tie in the standard firefighting orders, “the 10’s” and watchout situations, “the 18’s” that incorporate safety into each daily lesson. Students also tested in the fire fit challenge, which includes running a mile and a half, and maximizing the number of pushups, sit-ups and pull-ups they can do in three minutes during their first week of class. They were tested again on the last day for the physical training aspect of the class.

Students spent time in the field with park forester Brain Verhulst to learn about tree health and park ecologist Scott Esser to learn about succession and fire’s effect on ecosystems.

Instructors and students spent many hours at the sand table, a large sandbox with props, working out scenarios and applying what they learned about fire suppression. Students also spent a day acting out a fire field scenario with Cerda and Alpine Hotshot Captain Mark Mendonca.

Dressed in full personal protective equipment, the students gathered tools and hiked into a simulated “fire” area, received a briefing and dug fire lines. They followed a designated escape route to a deployment zone, where each student deployed a practice fire shelter. A debriefing back at the school assessed what they learned.

“The students learned more in this course than just the science of wildland firefighting,” Baldwin said. “They learned about the hotshot’s core values of safety, duty, respect and integrity. They learned about hard work, team work and personal development. And they learned the importance of physical fitness.”

Seventeen-year-old Franco Casas of Los Angeles said he was inspired to take the class by Carrillo’s experience with the Alpine Hotshots.

“(The) class gave me a different perspective. I thought all fires were bad, and you just put them out. But then we learned about fire in the ecosystem,” he said.

Casas, who said opportunities are rare back in his L.A. home neighborhood, wants to pursue becoming a hotshot. “It’s a dangerous job, but it’s challenging,” he said. “They train like they fight, and it’s always safety first.”

For 19-year-old Jeremy Coles, the course taught him a lot about what it means to be a leader.

“Working with the Alpine Hot Shots encouraged me to be more on top of my game with life skills and working as a team, being a leader to make class smooth,” said Coles. “Meeting people from RMNP opened up doors for my future.”

The mixture of classroom teaching, field exercises and hands-on science kept the students engaged.

Student Valentina Ramirez, who is from the same East L.A. neighborhood as Cerda, said the class went well beyond her expectations. “I just thought we’d hear from (hotshots) about their experience,” she said. “I didn’t know we’d get to use their tools, and even the fire shelter. I didn’t know how dangerous firefighting was. I definitely have a greater appreciation for what firefighters do.”

For Eagle Rock instructor Jon Anderson, “Fire!” is a great example of the opportunities Eagle Rock has with Rocky Mountain National Park. “It’s good for diversity, and the internships and experiences for many of the students have been life-changing,” he said.

Eagle Rock School was founded on a vision that a school could improve the lives of young people by promoting community, integrity and citizenship. The school targets students who have not been successful in more traditional settings and also offers adults professional development opportunities to help strengthen schools both­ locally and nationally. The American Honda Education Corporation was founded as a nonprofit corporation in February 1991, and funds Eagle Rock School.

[Submitted by Traci Weaver and Holly Nickel ]

Reprinted from the National Park Service's "The Morning Report," July 17, 2014

Thursday, August 14, 2014

Food for Thought - Leadership Is...

"My own definition of leadership is this: The capacity and the will to rally men and women to a common purpose and the character which inspires confidence." ~ General Montgomery

"My own definition of leadership is this: The capacity and the will to rally men and women to a common purpose and the character which inspires confidence." ~ General Montgomery 

Tuesday, August 12, 2014

Authors of Our Own Lives - In the Space of Hard Choices

"Far from being sources of agony and dread, hard choices are precious opportunities for us to celebrate what is special about the human condition, that the reasons that govern our choices as correct or incorrect sometimes run out, and it is here, in the space of hard choices, that we have the power to create reasons for ourselves to become the distinctive people that we are." ~ Ruth Chang

 In Leading in the Wildland Fire Service, we state: "Leaders often face difficult problems to which there are no simple, clear cut, by-the-book solutions. In these situations, leaders must use their knowledge, skill, experience, education, values, and judgment to make decisions and to take or direct action—in short, to provide leadership."

Wildland fire leaders are required to make hard decisions--decisions that affect others. Knowing what makes a decision hard and how to manuever within the decision space requires a leader to reflect upon themselves, to know their values and how their "normative power" creates reason.

Take a moment and watch Ruth Chang's video "How to Make Hard Choices" TedTalk video.

Video Highlights

  • Understanding hard choices uncovers a hidden power each of us possesses.
  • In a hard choice, one alternative is better ins some ways, the other alternative is better in other ways, and neither is better than the other overall.
  • Hard choices are hard not because of us or our ignorance; they're hard because there is no best option.
  • We unwittingly assume that values like justice, beauty, kindness, are akin to scientific quantities, like length, mass and weight.
  • Each of us has the power to create reasons.
  • When alternatives are on a par, the reasons given to us, the ones that determine whether we're making a mistake, are silent as to what to do. It's here, in the space of hard choices, that we get to exercise our normative power, the power to create reasons for yourself... 
  • People who don't exercise their normative powers in hard choices are drifters. Drifters allow the world to write the story of their lives.

Hard choices are precious opportunities for us to celebrate what is special about the human condition. - Ruth Chang
Wildland Fire Leadership Challenge - Digging a Little Deeper

Monday, August 11, 2014

Food for Thought

"Earn your leadership every day." ~ Michael Jordan

"Earn your leadership every day." ~ Michael Jordan

Friday, August 8, 2014

Ruby Mountain Hot Shot Crew Wins BLM Fitness Challenge

Ruby Mountain Interagency Hotshot Crew

The Ruby Mountain Interagency Hot Shot crew was recently awarded the BLM Interagency Hot Shot Crew Fitness Challenge Trophy for having the crew with the highest average physical fitness score of 11 crews across the nation…

The purpose of the BLM National Fire Operations Fitness Challenge is to create a system that measures an individual's level of fitness, help them create goals, track their fitness improvements and provide recognition for individual efforts. The Ruby Mountain Hot Shots scored an average 312.6 points with the top score belonging to Tim Hart with 381 points.

Ruby Mountain Interagency Hotshot Crew

The IHC Fitness Challenge Trophy was created to take fitness a step further and promote healthy competition between the BLM Interagency Hotshot Crews. The trophy features two full size Pulaskis with all 11 BLM Hotshot Crew's insignias etched into the handles, multiple placards for commemorating each year's victor and a hook for hanging the current trophy holders hard hat during the year of their accomplishment.

The test consists of four exercises: push ups, pull ups, sit ups and a 1.5 mile or 3 mile run. The individual is given points for each category which is then totaled and averaged for the crew. In 2013 – its inaugural year - the Midnight Sun Interagency Hotshots of BLM Alaska were awarded the trophy for averaging a score of 311 out of a possible 400 points.

"This award is a great accomplishment for the crew and it shows that our employees are dedicated to their fitness and setting the example for the fire community," said Ruby Mountain IHC Superintendent Craig Cunningham. "If you want to be the best, then you have to beat the best."

By: Lesli Ellis-Wouters, BLM Nevada

Reprinted from "The BLM Daily," July 22, 2014