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Epic Human Failure on June 30, 2013

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Advances in Human Error, Reliability, Resilience, and Performance (AHFE 2017)

Part of the book series: Advances in Intelligent Systems and Computing ((AISC,volume 589))

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Abstract

Nineteen Prescott Fire Department, Granite Mountain Hot Shot (GMHS) wildland firefighters and supervisors (WFF), perished on the June 2013 Yarnell Hill Fire (YHF) in Arizona. The firefighters left their Safety Zone during forecast, outflow winds, triggering explosive fire behavior in drought-stressed chaparral. Why would an experienced WFF Crew, leave ‘good black’ and travel downslope through a brush-filled chimney, contrary to their training and experience? An organized Serious Accident Investigation Team (SAIT) found, “… no indication of negligence, reckless actions, or violations of policy or protocol.” Despite this, many WFF professionals deemed the catastrophe, “… the final, fatal link, in a long chain of bad decisions with good outcomes.” This paper is a theoretical and realistic examination of plausible, faulty, human decisions with prior good outcomes; internal and external impacts, influencing the GMHS; and two explanations for this catastrophe: Individual Blame Logic and Organizational Function Logic, and proposed preventive mitigations.

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Acknowledgements

The authors wish to express their appreciation to: Dr. Martha Underwood, Patricia Burch, and Jill Cobb for their proficient knowledge and skills in managing this paper; Dr. Ted Putnam for his Human Factors insight; sources that are mandated to be uncooperative, due to Department and/or Agency ‘YHF direction,’ fear, threats, and/or intimidations; and sources that know a lot, keenly choosing to remain silent. To those who lost family, friends, and loved ones on the YHF, the authors and most WFF think about those young men daily, and this is a means toward healing and optimistically, averting similar future wildfire tragedies.

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Authors and Affiliations

  1. Sheff LLC, Pine, USA

    Fred J. Schoeffler

  2. Prineville, USA

    Lance Honda

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  1. Fred J. Schoeffler
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  2. Lance Honda
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Editors and Affiliations

  1. Idaho National Laboratory, Idaho Falls, Idaho, USA

    Ronald Laurids Boring

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Schoeffler, F.J., Honda, L. (2018). Epic Human Failure on June 30, 2013. In: Boring, R. (eds) Advances in Human Error, Reliability, Resilience, and Performance. AHFE 2017. Advances in Intelligent Systems and Computing, vol 589. Springer, Cham. https://doi.org/10.1007/978-3-319-60645-3_12

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  • DOI: https://doi.org/10.1007/978-3-319-60645-3_12

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  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-60644-6

  • Online ISBN: 978-3-319-60645-3

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