The cultural change process has two "schools of thought." One is the "bottom-up" theory in which the changes must arise from those actually doing the work. The second is the "top-down" theory in which cultural changes are made by direction from the top down. The reality is that both are essential to a cultural change! Changing the wildland fire organizational culture will require a clear understanding, cooperation, and commitment from all organizational levels. Change is also dependent on leadership. Culture is changed by a series of small steps taken by the leading members of the culture at all levels.
In all, 34 firefighters lost their lives the summer of 1994.
We've learned many things from South Canyon, and from other fatality fires as well. Sure we've changed procedures. We've added new rules, new training, and new methods for analyzing and correcting our mistakes. But as painful as death in firefighting is, the lessons threaten to fade in time. This is because the changes we make to prevent future fatalities won't make the critical difference we need unless we begin to look at the behaviors that lead to the tragedies. In short, our firefighting culture must change. We must embrace the strengths in our culture (and there are many), but be willing to give up the weaknesses in favor of improvement and change. In other words, we look forward to an evolution - not a revolution, in firefighter culture.
In a study of the safety culture of NASA's aerospace crews, researchers define culture as the values, beliefs, rituals, symbols and behaviors we share with others that help define us as a group. Taking this one step further, they say a culture's surface structure includes observable behaviors while its deeper structure consists of the values and beliefs that, in turn, guide a person's actions. These cultural "characteristics" are then transmitted to succeeding generations.
The firefighting culture began defining itself nearly a century ago. And it was played out in Wyoming's Blackwater fire tragedy of 1937. Fifteen firefighters perished in this blaze when they were trapped by an undetected spot fire. In the face of unfathomable odds, the men chose to attack the fire instead of escape. According to Stephen Pyne in his 1982 book, Fire in America, the forest supervisor lauded subsequent efforts to contain this fire saying firefighters "rose to the occasion like veterans, and at daylight three crews were on the fireline carrying on determined to whip the fire that had beaten them so terribly the afternoon before."
Firefighting a culture grounded in heroism and likened to war, where risk-taking is glorified and rewarded, then amplified through the pens of journalists, and passed on to the rookies, decade after decade.
So, lessons came. We learned. Changes were made. But time passed, and the lessons faded.
Two things became very clear to us following the tragedy of South Canyon in 1994. First, the changes we had made in the past were not enough to prevent fatalities on wildland fires. Second, the procedures we established to protect the lives of our firefighters were worthless if they were disregarded in the face of cultural beliefs that implicitly, and explicitly, equate the fireline with the battlefield. The time had come to approach firefighter safety differently than ever before.
These are some of the things the firefighters had to say: 1) "Until the [Agency] recognizes that we are professionals and we are treated as such you will continue to lose some of the best and the brightest;" 2) "The ICS system is good, but MANY individual positions are filled by inexperienced people...;" 3) "No blame is ever placed on individuals;" 4) "Accountability is our major concern."
All in all, when the surveys and interviews were finished, we found many more firefighters expressed the same concerns. Increase firefighter experience, training, and physical fitness. Hold all ranks accountable for unsafe performance or decisions. Make sure supervisors have the temperament, training and experience to supervise during emergencies. Improve attitudes toward safety.
Attitudes. Accountability. Experience. These were the concerns uppermost in the minds of our firefighters and managers in the field. One Montana hotshot said "We understand the science of fighting fires, but we do not understand the science of people fighting fire."
From the Safety Awareness Study we began to learn what was broken. Next, we had to decide how to fix the problems.
The second phase of the Safety Awareness Study suggested 86 changes that would help make safety the first priority. Not just in rhetoric, but in every decision and in every action. The suggested changes are immense and complex. They range from how we conduct firefighter training to our personal code of conduct. From interagency cooperation to developing new technology. From hazardous fuels reduction to public education.
With a list of the problems in one back pocket and suggested changes in the other, we've begun Phase III of the Safety Awareness Study implementation. We call this implementation "Safety Awareness in the Fire Environment," or "SAFE" initiative. Under SAFE, we took 11 principles, 86 goals and 227 implementation strategies developed by TriData, and merged them into nine focus areas that will help wildland firefighting agencies focus on adjusting a culture to one where safety is a value that translates into behaviors.
The nine focus areas include interagency cooperation, incident operations, program oversight, equipment, external influences, safety culture, safety information database, healthy workforce and situational awareness. These focus areas are not necessarily in priority order.
Area 1. Interagency Cooperation. We can improve interagency working relationships by encouraging and assisting non- federal agencies to obtain equipment, training, and operational parity with the federal agencies and vice-versa. We can continue to improve cooperation in a wide range of activities among the federal agencies.
Area 2: Incident Operations. We can improve the effectiveness and consistency of incident operations by: updating and improving incident management training; developing and clarifying policies and procedures; developing job aids and new technology; enhancing and encouraging interpersonal communications; defining, developing and ensuring certification, redcards, and currency; improving training methods, procedures and instructors; improving communications skills; developing on-the-job training; and line officer education; and implementing a strategy to recruit, develop, maintain, honor and retain workforces of capable firefighters.
Area 3: Program Oversight. We must continue to provide information and education to supervisors on program leadership and oversight responsibilities within wildland fire to facilitate safe, effective policies, implementation strategies, and budget requests consistently across agencies. We can do this by: establishing and enforcing minimum requirements for key leadership positions; encouraging more participation in the fire program from non-fire personnel; re-examining and clarifying the role and organizational placement of Safety Officers; removing pay caps for overtime on fires; and considering expanding the use of special pay and retirement incentives for collateral duty personnel.
Area 4: Equipment. We must provide equipment to incidents within acceptable time frames, in good working order and in quantities sufficient to support the incident. This means: improving distribution of radios, batteries, and other communication equipment; describing equipment maintenance responsibilities in basic courses; and holding users and cache operators responsible.
Area 5: External Influences. We must foster coordinated public education and outreach programs to disseminate prevention information, fuel reduction program information and the capabilities/limitations of firefighting resources.
Area 6: Safety Culture. We must institutionalize safety as a core value throughout the fire program. We can do this by: following-up on reported safety infractions; removing violators from the job; training new firefighters to speak up about safety issues; providing guidelines for accountability; training supervisors to listen; promoting a single code of conduct across all agencies; and developing an attitude and ethic of professionalism that encourages retention and promotes safe behaviors.
Area 7: Data Management. We need to acquire, manage, and analyze information to identify accident trends and to provide real-time safety information. We can do this by: developing a common interagency reporting system; analyzing and publishing safety data; establishing a safety-oriented "Center for Lessons Learned;" and developing interagency protocols for the process and substance of investigations.
Area 8: Healthy Workforce. We need to define and develop a healthy workforce and environment. One example of this is the Work Capacity Test which measures wildland firefighter fitness based on the level of fitness required to safely perform the physically demanding work in difficult environments. This test is intended to help ensure the safety and health of each firefighter and his or her co-workers, in addition to improving efficiency. We may also: require contractors at federal wildland fires to meet the new physical fitness test; reduce the duration of field assignments; conduct furthers studies of sleep deprivation, impacts of smoke, and others factors that could affect wildland firefighter performance.
And finally Area 9: Situational Awareness. We need to define and develop situational awareness concepts in all fire operations. This means: teaching techniques for maintaining situational awareness in training courses designed for personnel from firefighters to incident commanders; using satellite imagery; using real-time air-to-ground and ground-to-air video, and other technologies; and keeping firefighters informed about conditions.
We must recognize the strengths in our "values, beliefs, rituals, symbols and behaviors." And we must recognize that the needed changes to our culture cannot be made overnight. Behaviors and attitudes learned and practiced and passed on generation after generation cannot be re-learned or assimilated through proclamations or declarations. As Merritt and Helmreich write in their NASA study "While it may be possible for management to direct people to change their work behavior, management cannot direct people to change their values. Without the underlying values in place to guide the behavior, behavior shifts will be short- lived." Cultural change is done a little at a time, over a long period of time.
The firefighting culture began defining itself a century ago. We must begin re-defining this same culture immediately. We need to define what this culture will look like in the year 2010 or 2050.
One way for us to accomplish this is to focus on what I consider to be important catalysts for this change: improve accountability, clearly define management responsibilities, and recognize firefighting as a profession.
Accountability. Accountability means taking responsibility for one's actions. It means understanding that you and you alone are to be held liable for every decision or act. Accountability must reach far and wide to every manager who has responsibilities related even remotely to fire, and to every person wielding a shovel on the line. Each individual must monitor his or her actions and behaviors; each individual must re-think his or her values and beliefs. And when an individual violates safety rules or compromises safety, it means penalties. We can no longer allow safety violators to go unpunished, or the safety violation to be suppressed or hushed-up. We must openly discuss incidents and safety breaches as they occur in order to truly focus on lessons learned, and to establish safety as our top priority.
Management responsibility. Standards in firefighting have been established. These standards can only be met through drilling, and through realistic practice and training. Crews need time to practice firefighting techniques, and they need time to maintain their tools and physical condition. Managers must understand their responsibilities and acknowledge the importance and critical nature of these standards and make sure crews adhere to them. Because in the end, the managers will be held responsible, as well as the crews, for infractions.
Finally, professionalism. What does a professional wildland firefighting organization look like? To me, it consists of managers who think about what they're asking firefighters to do and how the crews will accomplish the request. A professional organization is one led by managers who establish standards, help their crews meet the standards and then enforce the standards. It's composed of highly trained and competent individuals who uphold the standards of wildland firefighting. A professional organization consists of incident commanders and crew bosses who constantly think of ways to minimize risks. Incident commanders and crew bosses who aren't afraid to question a decision or request and can react quickly and professionally to changing situations. A professional wildland firefighting organization is one composed of firefighters who are proud to point out a safety problem and the solution. Last and possibly most important, a professional organization consists of firefighters who have a code of conduct not a code of silence.
Lessons learned. Changes made. So how do we now keep the lessons we've learned alive? We believe we must change a culture one that's based on heroism and risk-taking. One that's been equated to war for a century and one with real-life heros.
But a culture that's taken decades to define itself does not change overnight. We must change values and beliefs that have glorified heroism and risk-taking for many decades; values and beliefs that continue to dictate our behaviors and actions. This process will take commitment, time and hard work.
The TriData study gave us the building blocks, or bricks. Now we must build the house. However, before we can build the house, we must draw up a plan. A plan that describes how we can achieve the implementation strategies before us. How we can "foster a culture," "develop an attitude," "encourage a code of conduct." This plan must involve the fire community and management at all levels. We must partner both within and outside the fire community for the skills we need to truly change our culture.
We can, however, begin making some changes immediately; in fact it is clear to protect our firefighters on the ground we must begin NOW to make changes. We must begin now to behave and make decisions as if our lives depend on it because they do!
We must change how we perceive safety. We can no longer think of safety only as "an attitude" or "common sense." We must change our values and beliefs to reflect safe firefighting behaviors as intrinsic to a profession-our profession. We must define a new culture where safe behaviors are practiced by everyone, from the agency administrator to the firefighter on the line. A culture where each member is held accountable for her or his actions. And above all we must consider ourselves professionals and act that way. Sure, wildland firefighting is a dangerous business and inherently risky. However, professional wildland firefighters do not look for opportunities to become heroes. Instead they understand the danger of their business and look for ways to minimize risks.
We know we have years of difficult work ahead of us. We know cultural change takes time. It's easy to create mission statements, write policy, and change organizational structure. But these reforms have little impact on cultural change. And the changes that will provide the real measure of our success will be the most difficult to accomplish. We must change what we do on a day-to-day basis-how we reward people both formally and informally, and how we, as leaders in wildland firefighting, handle tough situations.
We know we have work to do and that working toward this cultural change will take time. But we also know that we must begin now.
National Office of Fire and Aviation
Bureau of Land Management
Merritt, A.C., and R.L. Helmreich. 1996. "Creating and
sustaining a safety culture: Some practical strategies." CRM
Pyne, Stephen J. Fire in America: A Cultural History of
Wildland and Rural Fire. Princeton University Press. 1982.
TriData Corporation. 1996. "Wildland Firefighter Safety Awareness Study."