# Presentation: 907456

## Fire Safety:  A Management Responsibility 

- Curt Braun, Ph.D
- University of Idaho
- _[cbraun@uidaho.edu](mailto:cbraun@uidaho.edu)_

**Notes:**
STS:  Shuttle Transportation System

Historically we see that the greatest advances in safety occur when management gets involved.  While it is commonly known that “safety is everyone’s responsibility” we now know that it is management that drives safe working conditions and practices.  

## Management’s Role

- Independent of industry, the role of management in ensuring safety cannot be understated.
-   “We should like to take a prominent part...in every movement that is practical to protect employees...and any requisition which is made for the expenditure of money to install equipment to protect our people will be honored.”  (Elbert H. Gary, Chairman of the Board, US Steel, 1908, in Aldrich , 1997)

**Notes:**
Steve Aldrich’s book Safety First  (1997) provides an in depth study of the progression of safety in the United States.  In it he tracks how the objectives of safety were initially marginalized by contract workers to a point when safety became a topic in boardroom discussions.  Motivated by changing perspectives on employee safety and the introduction of workers’ compensation programs, safety has become a key facet in American industry today.  Yet, because safety is a relative intangible when compared to products produced in a factory, it has been difficult to assign it an official home.  Given that safety as an objective permeates all activities within an organization, its primary seat of authority must reside somewhere within an organization that impacts all aspects of work.  It is for this reason that safety is largely a management responsibility.  Management possesses the position, resources, and authority to dictate how work is accomplished.  

The assignment of safety to management is not a guarantee in and of itself.  Just as a firefighter might be motivated to cut corners to achieve certain goals, managers too can be adversely influenced by factors unique to a company’s culture or history.  Unfamiliarity with the task to be performed, confidence developed over repeated “successful” outcomes, and a perception that dangers always exists and as such should be accepted can adversely impact management’s role as safety’s primary champion.  

NASA’s space shuttle program provides and excellent case study that shows how these factors can produce the appearance of safety while at the same time dismissing telltale signs of danger.  

## Slide 3

**Notes:**
The Columbia’s first flight occurred in April 12, 1981 and was the first shuttle to fly in space.  Two astronauts orbited the earth for 2 days and safely returned.  Before it’s destruction on February 1, 2003, the orbiter would complete 28 missions.  Columbia’s mission was the 128th flight in the shuttle program.

The orbiter flew three more times before the shuttle program was deemed operational on July 4, 1982.  The time to become operational was considerably shorter than expected.

There was a drive to declare the shuttle operational early in the flight program.  It was hoped that early operations would:
increase the likelihood of Presidential support for the next manned space mission
increasing competition for satellite launches from the European Space Agency

To attract commercial launch contracts NASA offered satellite launch missions at 1/3 of the actual cost.  The actual cost of a launch as $126 million.  NASA charged $42 million.  There was a clear motivation to become operational and become operational early.

## Slide 4

**Notes:**
By 1985 the shuttle program had launched 24 communications satellites and had a backlog of 44 orders.

In the process, NASA was learning more and more about the operations of the shuttle.  When initially designed, it was expected that the reprocessing of the shuttle would require 10 days.  In reality, it required 67 days to reprocess the orbiter.

Flights continued at a rapid pace until January 28, 1986.

## Slide 5

**Notes:**
On January 28, 1986 the Challenger Shuttle was destroyed when an o-ring and seal in the right solid rocket booster engine failed.

In August of 1986, then President Reagan announced that the shuttle would no longer be used for commercial operations.  

## The Challenger Investigation

*“**revealed a NASA culture that had gradually begun to accept escalating risk, and a NASA safety program that was largely silent and ineffective” * (CAIB Vol 1, p. 25).

**Notes:**
In many ways, Challenger was to NASA as South Canyon was to the wildland fire community.

In the 17 years between the Challenger and Columbia accidents, NASA had many changes.  The changes that appeared on the outside were not those that occurred on the inside. 

## Escalating Risk -- Challenger

- Problems with the solid rocket booster joint had occurred previously but were considered acceptable flight risks.
- Expected checks and balances within NASA’s safety system did not occur and the safety program was largely silent.
- Time demands reduced training, spare parts, and promoted nearsightedness among managers.

## NASA’s Response

- NASA implemented the organizational changes as outlined the Challenger investigation report.
- It created a safety organization that provided safety to programs based on the program’s funding.
- The Office of Safety and Mission Assurance at Headquarters was established.

**Notes:**
NASA implemented the organizational changes as outlined the Challenger investigation report. 

They created the Office of Safety and Mission Assurance At Headquarters to monitor and ensure communication and accountability agency-wide.

The shuttle program, however, was allowed to structure it’s safety program on its own which resulted in a lack of standardized structure throughout NASA’s various Centers.  Individual NASA Centers had to “buy” services from the Center’s safety organization.  The level of services was commensurate with the level of funding.

 From the outside, NASA made the recommended changes, but these changes were not what they appeared.

Driven by a enduring cold-war era, can-do culture NASA managers strove to maintain their view of the agency and “lost their ability to accept criticism, leading them to reject the recommendations of may boards and blue-ribbon panels, the Rogers Commission among them.”

## Slide 9

**Notes:**
Let’s fast forward to January 2003.

During the launch of STS-107 a piece of insulating foam detached from the bipod mounting point and damaged the leading edge of left wing on the orbiter.  

## Slide 10

## Slide 11

**Notes:**
THE ORBITER “RAN INTO” THE FOAM
“How could a lightweight piece of foam travel so fast and hit the wing at 545 miles per hour?” 
Just prior to separating from the External Tank, the foam was traveling with the Shuttle stack at about 1,568 mph (2,300 feet per second). Visual evidence shows that the foam debris impacted the wing approximately 0.161 seconds after separating from the External Tank. In that time, the velocity of the foam debris slowed from 1,568 mph to about 1,022 mph (1,500 feet per second). Therefore, the Orbiter hit the foam with a relative velocity of about 545 mph (800 feet per second). In essence, the foam debris slowed down and the Orbiter did not, so the Orbiter ran into the foam. The foam slowed down rapidly because such low-density objects have low ballistic coefficients, which means their speed rapidly decreases when they lose their means of propulsion. 

## Slide 12

**Notes:**
Figure 6.1-6. This chart shows the number of dings greater than one inch in diameter on the lower surface of the Orbiter after each mission from STS-6 through STS-113. Flights where the bipod ramp foam is known to have come off are marked with a red triangle.

The problem of foam shedding off the external fuel tank was not new.  “Photographic evidence of foam shedding exists for 65 of the 79 missions for which imagery is available. Of the 34 missions for which there are no imagery, 8 missions where foam loss is not seen in the imagery, and 6 missions where imagery is inconclusive, foam loss can be inferred from the number of divots on the Orbiter’s lower surfaces. Over the life of the Space Shuttle Program, Orbiters have returned with an average of 143 divots in the upper and lower surfaces of the Thermal Protection System tiles, with 31 divots averaging over an inch in one dimension.” 

Foam striking the orbiter was first noted on STS-7 in June of 1983.  Two flights before Columbia, considerable damage resulted from shedding foam.  NASA managers encouraged a review to be completed but this review was not accomplished until two more flights had been completed.

Why did this occur?

## Management’s Role (cont)

-   “The *Columbia* accident is an unfortunate illustration of how NASA’s strong cultural bias and its optimistic organizational thinking undermined effective decision-making.  Over the course of 22 years, foam strikes were normalized to a point where they were simply maintenance issue...” (Columbia Accident Investigation Board, 2003, p. 181).

**Notes:**
While it is true that management has served to advance safety, it has been shown to impede it.

## Management’s Role (cont)

-   “Even after it was clear from the launch videos that foam had struck the Orbiter in a manner never before seen, Space Shuttle Program managers were not unduly alarmed.  They could not imagine why anyone would want a photo of something that could be fixed after landing” (Columbia Accident Investigation Board, 2003, p. 181).

**Notes:**
The CAIB reported that, ““NASA’s safety culture has become reactive, complacent, and dominated by unjustified optimism (p.180).

The safety program inappropriately focused on showing how “safe” the program was rather than on showing how safe it was not.

The shuttle assessment team in 1999 noted that the “the Shuttle Program was inappropriately using previous success as a justification for accepting increased risk; the Shuttle Program’s ability to manage risk was being eroded “by the desire to reduce costs;” the size and complexity of the Shuttle Program and NASA/contractor relationships demanded better communication practices; NASA’s safety and mission assurance organization was not sufficiently independent; and “the workforce has received a conflicting message due to the emphasis on achieving cost and staff reductions, and the pressures placed on increasing scheduled flights as a result of the Space Station” [emphasis added]

## Fire Management: Paradox

- For many line managers, fire is a responsibility but not a competency.
- Systems designed to promote safety may themselves suffer from unreliability and be adversely influenced by “success.”

## 2006 Incidents

- “Fuel was very heavy is this area, which in return contributed to the entrapment.” Chisholm Fire April 2006
- “Extreme fire behavior and expected weather changes were not given adequate consideration when planning strategy and tactics.”  Mudd Fire August 2006.

## 2006 Incidents (cont.)

- “Statewide fine fuel carryover is estimated around 70% to 90% above normal adding to the continuity of the fuel bed. Fuel loadings in fine fuels are heavy averaging 1500 to 2000 pounds dry weight.”  New York Peak Fire, July 2006
- Fire behavior changes from 5’ to 20’ in fine flashy fuels.” Moundville Fire, March 2006

## 2006 Incidents (cont.)

- “Fire experienced extreme wind event from passing thunder cell” Scorpio Fire, July 2006
- “The weather combined with heavy fuels created extreme burning conditions. These weather conditions were not forecasted in the morning fire weather.” Sawtooth Complex, July 2006

## 2006 Incidents (cont.)

- “Fire activity steadily increased on July 18 and eventually became extremely active,...” Little Venus, July 2006
- “both longterm and short-term weather and fuels trends contributed to volatile fire conditions” Devils Den, August 2006

## Other 2006 Incidents

- New Holland – entrapment during prescribed fire.
- Sabine Fire – entrapment during prescribed fire.
- Tallahassee Burnover
- Devils Den – Burnover, fatality
- Ball Canyon – Deployment
- Clubhouse – Burnover
- Esperanza – Burnover
- Rivera Mesa -- Entrapment

## LM Fire Safety Described

- A recent BLM survey evaluated the training of LMs by asking FMOs and LMs to rate performance (BLM, 2002).
- The evaluation distilled 27 LM performance requirements into 5 dimensions:
- 1.  Safety				4.  Prescribed fire
- 2.  Resource management	5.  Oversight
- 3.  Reviews

**Notes:**
The LM responsibility for fire safety is clear.  What that actually entails, however, has not be detailed in any way.  A recent BLM survey, however, represents the first effort to describe the safety responsibilities of LMs.  Starting with the the Standards for Fire and Aviation Operations 2001 (i.e., the RedBook), a Leadership Academy Team evaluated and condensed the 27 Field Office Manager Management Performance Requirements listed in chapter 2 of the RedBook.  Currently the BLM Director, State Directors, and Field Office Managers are obligated to meet these requirements called competencies. 

Using a statistical procedure called hierarchical cluster analysis, the team reduced these 27 competencies into six dimensions of fire management.  These dimensions were safety, resource management, reviews, prescribed fire, preparedness, and oversight.  

## Safety Responsibilities

- The evaluation team, with SMEs, divided safety responsibilities into two categories:
- Safety participation
- Safety communication
- Excellent, acceptable, and poor behavioral examples were developed with SMEs.
- Rating of LMs were given by FMOs and LMs.

## Excellent Safety Participation (5)

- LM participates in pre-season discussions with fire staff on safety requirements and concerns.
- LM, FMO, and IC work together to develop safety policy and plans that promote firefighter and public safety first, and determine how requirements (e.g., work/rest) will be implemented on the incident.
- LM ensures that all actions are conducted in a safe work environment.

**Notes:**
Excellent (rating = 5): LM participates in pre-season discussions with fire staff on safety requirements and concerns.  LM, FMO, and IC work together to develop safety policy and plans that promote firefighter and public safety first, and determine how requirements (e.g., work/rest) will be implemented on the incident.  LM ensures that all actions are conducted in a safe work environment.  

Acceptable (rating = 3):  LM ensures that risk assessments are completed for fire staff activities.  LM meets with fire staff to review safety policies; Emphasizes safety in pre-season briefings and follows up on deficiencies.  Supervisors are responsible for corrective actions.

Poor (rating = 1): LM relies on fire staff to communicate safety issues to firefighters and only discusses safety when an accident occurs.  LM relies on FMO to complete risk assessments for fire related activities.

## LM ensures that risk assessments are completed for fire staff activities.  
LM meets with fire staff to review safety policies; Emphasizes safety in pre-season briefings and follows up on deficiencies.  Supervisors are responsible for corrective actions.

- LM meets with fire staff to review safety policies; Emphasizes safety in pre-season briefings and follows up on deficiencies.  Supervisors are responsible for corrective actions.

- Acceptable Safety Participation (3)

## LM relies on fire staff to communicate safety issues to firefighters and only discusses safety when an accident occurs.  
LM relies on FMO to complete risk assessments for fire related activities.

- LM relies on FMO to complete risk assessments for fire related activities.

- Poor Safety Participation (1)

## Safety Participation

**Notes:**
46 FMOs and 46 LM

## Excellent Safety Communications (5)

- LM communicates expectations for ff safety in planning, pre and post-season briefings, training, and visits to the fire.
- LM maintains contact with Incident Commander (IC) as fire progresses and holds IC accountable for compliance with rules.
- LM works closely with communities to identify protection zones, and supports suppression actions that ensure firefighter and public safety above other objectives.

## LM communicates safety expectations and requires FMO to talk about safety at briefings.  
LM encourages use safe tactics on the fire line.  FMO has responsibility for encouraging reduction of fuels hazards near communities.

- LM encourages use safe tactics on the fire line.  FMO has responsibility for encouraging reduction of fuels hazards near communities.

- Acceptable Safety Communications (3)

## LM relies on safety officer and FMO to work with communities to develop a safety plan.  
FMO and IC are expected to monitor firefighter and public safety concerns.

- FMO and IC are expected to monitor firefighter and public safety concerns.

- Poor Safety Communications (1)

## Safety Communications

## Training Effectiveness

**Notes:**
Safety 1 = communications
Safety 2 = participation

## Participation Defined

- LM participates in pre-season discussions with fire staff on safety.
- Create / review safety objectives for upcoming fire season.
- Review and evaluate prior year’s performance.
- Identify programmatic changes and initiate actions to implement and follow up.
- Identify and resolve known and anticipated hazards.

## Participation (cont)

- LM works with FMO to develop safety policies that promote firefighter and public safety.
- View fire as both a natural and social phenomenon.
- Develop and implement policies appropriate to the phenomenon.
- Discuss factors that can adversely impact firefighter and public safety: uncertainty and overconfidence.

## Participation (cont)

- LM works with FMO to implement safety requirements on incident.
- Operationalize objectives.
- An operational definition identifies how a state is created or measured.
- Creating definitions gives LMs the ability to assess progress toward goals.

**Notes:**
Operational Definitions and Management Objectives 
Operational definitions apply nicely to incident objectives.  Consider this objectives, "Provide for the safety of firefighters."  Although desirable, this objective must be further defined before it has any useful meaning.  Two possible definitions for this objective are shown below.  The first defines safety according to the method used to create it and the second defines it by how it might be measured. 
Safety:  How it is createdFirefighter safety is defined as the systematic use of a comprehensive hazard system (e.g., 215a, job hazard analysis, risk assessment process) that identifies hazards and appropriate mitigations.  Safety would be created by implementing all mitigation measures on the 215a and other risk assessment processes (e.g., go/no go aviation checklist). 
Safety: How it is measuredFirefighter safety can be assessed by calculating the number of injuries to line going crews on a daily basis.   The daily injury incident rate will not exceed 5 injuries per 100 firefighters per year and the fire average will not exceed 4.0 injuries per 100 firefighters per year.
By operationally defining the safety objective, it is possible to assess the team's performance and keep tabs on its progress.  It would be possible, for example, to collect all of the 215a as evidence that the team was "providing for firefighter safety."  You could also look at the injury incident rates.  A fire with an injury rate greater than 4 would have not fulfilled the objective.  In other words, it did not provide for firefighter safety.  Operationally defining objectives provides the incident management team with a starting point and a means of evaluating performance.  
Operationally defining objectives provides the incident management team with a starting point and a means of evaluating performance.  By using the 215a or other risk assessment processes, each operational period, safety can be measured by "did we or how did we provide firefighter safety; was it successful?  What further actions are needed to measure firefighter safety?  What will we not do if we can't provide mitigation as identified in the risk assessment process?

## Participation (cont)

- LM ensures actions are conducted in safe environments.
- LMs are not likely to control the physical environment.  They, however, can:
- Outline performance expectations (administrative controls) and where work can occur.
- Promote conservatism when firefighters are directed to fight fire aggressively.

**Notes:**
Outline performance expectations.  What do you want firefighters to do when faced with uncertainty?  Or something of that matter.  

## Safety Communications

- LM communicates expectations for firefighter safety in planning, pre and post-season briefings, training, and visits to the fire.
- LM expectations set the tone for future fire related activities.
- LM expectations direct actions and can cause closer evaluation of planned actions.

## Safety Communications (cont)

- LM maintains contact with IC as fire progresses and holds IC accountable for compliance with rules.
- Delegation of authority does not preclude involvement.
- Using operational definitions, LM can assess team’s progress and compliance.
- LM can influence team’s actions.

**Notes:**
LM can influence team’s actions in many directions.  In some instances, the team may be looking for permission to not engage the fire.

## Safety Communications (cont)

- LM works closely with communities to identify protection zones, and supports suppression actions that ensure safety above other objectives.
- The social component requires planning.
- It’s essential that LMs and FMOs identify and resolve conflicts between safety, protection zones, and suppression actions before incidents occur.

## Resolving the Paradox

- Do participation and communication eliminate risk?
-  They are good starting points.
- They, however, only represent the observable aspect of a safety program.

**Notes:**
It’s not likely that these two components of safety will address all aspects of risk; however, it’s a good starting place.

Oddly, LM are often left to devise and implement safety programs of their own.  In the absence of a developed risk management program, here’s is my advice.

What is behind this participation and communication?

## Management Actions

- Employ your agency’s risk management process.
- Never cease to ask questions and evaluate responses about tactics and safety.
- Scrutinize the events of past tragedies and successes.

## Management Actions (cont.)

- Focus on the process.
- Encourage staff to defend proposed actions.
- Close the loop.
- Make your position known and ensure compliance with it.