8 USDA Forest Service RMRS-GTR-201. 2007
Keller, Paul, technical writer-editor. 2004. Managing
the unexpected in prescribed re and re use opera-
tions: a workshop on the high reliability organization.
Santa Fe, New Mexico, May 10-13, 2004. Gen. Tech. Rep.
RMRS-GTR-137. Fort Collins, CO: U.S. Department of
Agriculture, Forest Service, Rocky Mountain Research
Station. 73 p. Available: http://www.wildrelessons.net/
HRO.aspx [July 6, 2007].
Annotation: Keller’s report summarizes the 4-day Managing
the Unexpected Workshop held in Santa Fe, New Mexico, on
May 10-13, 2004. This workshop focused on how to apply
high reliability organizing concepts and how to overcome
personal immunities to change within the prescribed re
and wildland re use communities. A central activity of the
workshop was a “staff ride,” where attendees learned about
the Cerro Grande prescribed re, which escaped and burned
into Los Alamos, NM, in May 2000. The staff ride allowed
participants to gain insights into the application of the high
reliability organizing concepts that contribute to mindful-
ness and ultimately enhance the capability to discover and
manage unexpected events. These concepts, drawing from
Weick and Sutcliffe’s book, “Managing the Unexpected,”
include a preoccupation with failure, reluctance to simplify,
sensitivity to operations, commitment to resilience, and def-
erence to expertise (see Weick and Sutcliffe 2007 in Section
III.B.2.). Participants were immersed in these concepts in
order to learn how to integrate them into their future work
at both the local and national levels.
Keywords: high reliability organization, organizational
learning, sensemaking, Cerro Grande
Mangan, Richard. 1999. Wildland re fatalities in the
United States: 1990-1998. Tech. Rep. 9951-2808-MTDC.
Missoula, MT: U.S. Department of Agriculture, Forest
Service, Missoula Technology and Development Program.
17 p. Available: http://www.fs.fed.us/t-d/pubs [July 6,
2007].
Annotation: While reports on specic fatalities and re
entrapments are prepared annually, such information is
typically presented without interpretations or recommenda-
tions. This summary of re fatalities reexamines the annual
report data and offers specic recommendations for im-
proving safety and reducing fatalities. Mangan’s summary
notes that burnovers make up less than 20 percent of the
total causes of fatalities on res. Other sources of fatalities
include aircraft accidents, heart attacks, vehicle accidents,
falling snags, and other miscellaneous causes. Managers
can reduce the risk of fatalities by encouraging individual
responsibility, maintaining good physical tness, ensuring
continued re behavior training, improving re ghting
strategies and tactics, and using protective clothing and
equipment.
Keywords: reghter safety
Mangan, Richard. 2002. Injuries, illnesses, and fatali-
ties among wildland reghters. Fire Management Today.
62(3): 36-40.
Annotation: Mangan discusses some of the physical and en-
vironmental demands placed on reghters that contribute
to injuries, illnesses, and fatalities. He makes recommen-
dations about clothing, hydration, diet, sleep, and physical/
emotional stress in order to reduce many of the potential
health risks common to the reghting profession.
Keywords: health, injury, stress
OSHA. 1995. Occupational Safety and Health
Administration’s investigation of the South Canyon re,
February 8, 1995. Washington, DC: U.S. Occupational
Safety and Health Administration. 9 p.
Annotation: On July 7, 1994, the Occupational Safety and
Health Administration (OSHA) began a formal and inde-
pendent investigation into the health and safety factors
leading to the deaths of one Bureau of Land Management
and 13 Forest Service reghters during the South Canyon
Fire of 1994. This investigation reviews events leading to
the tragedy, makes recommendations, and cites nine unsafe
conditions or practices that contributed to the tragic deaths
of these workers, including such things as the identity of
the Incident Commander, inadequate safety zones, escape
routes, weather forecasts, re lookouts, downhill reline
construction, and various management failures.
Keywords: reghter safety, South Canyon, OSHA
Putnam, Ted. 1995a. Findings from the Wildland
Fireghters Human Factors Workshop. Improving
wildland reghter performance under stressful, risky
conditions: Toward better decisions on the reline and
more resilient organizations. June 12-16, 1995; Missoula,
MT. Missoula, MT: U.S. Department of Agriculture, Forest
Service, Missoula Technology and Development Center.
Available: http://fsweb.mtdc.wo.fs.fed.us [July 6, 2007].
Annotation: The 1994 re season, when 34 people died, was
the catalyst for this 5-day workshop, where reghters, safety
managers, psychologists, and sociologists discussed the role
of human factors in reghter safety. Workshop participants
examined reghters, reghter crews, re management,
re culture, and re communities with the goal of creat-
ing a more resilient organization for reghter safety. The
workshop began with four keynote speakers (Kurt Braun,
David Hart, Gary Klein, and Karl Weick) who discussed
human behavior, recognition-primed decision strategies,
cultural attitudes, and insights from high reliability orga-
nizations (HROs) pertinent to improving communication,
leadership, group structure, and sensemaking, which in turn
can decrease stress and the chance of catastrophic errors.
Participants took a eld trip to Mann Gulch, where they dis-
cussed, from a psychological perspective, how and why 13
reghters died there. The nal 2 days of the workshop were
spent exploring solutions and developing long-term and
short-term recommendations. This publication summarizes