#30 - Maneuver to Safety, Part 2: Ditch and Innovate

In Post #29 (Divert and Experiment), Jess and Jamie paddled for the middle of Lake Insula, to get away from the fire headed in their direction. But then the lake itself grew so turbulent they couldn’t stay in their canoe. So they ditched their gear and canoe, and decided to attempt the first fire shelter deployment in deep water.

It didn’t go as planned….

Forced to go against training

Here’s what happened when Jess and Jamie tried to deploy fire shelters:

Their shelters are partly unfolded, but in the wind and waves, it’s hard to get them open all the way. They decide to let a shelter go—they’ll share one and stick together.¹

That move was wild.

As an investigator, I never heard of someone throwing a fire shelter away.

As a firefighter I never dreamed of doing it. Your fire shelter is supposed to be your last-ditch survival option. It’s the one thing we are trained never to let go of. My crew used to do drills where we were cutting fireline and we had to sprint to safety: in those drills, you drop your gear, drop your tool… but whatever you do, you grab your shelter, and you hang onto it. We drilled on that, so it would be second-nature in an emergency. Throwing away a shelter violates all training. Just writing about it now it makes me uneasy.

So, Jess’s decision to throw away a shelter was wild. But it’s what had to be done. Why? Because her mission was to keep herself and Jamie safe. And based on that mission, they had to do the unthinkable; they had to ditch their last-ditch tool.

The upper arrow shows Jess and Jamie’s path of travel. View is from the northwest. Campsite 8 is well above the main lake in the photo. A note for investigators—look at how benign the scene appears. It was taken from the air, well after the entrapments. You see the whole scene, in the clear light of day; the fire is out; the winds are calm; the water is glassy. You can almost hear birds chirping—it’s that pristine. This point of view is deceptive. It has absolutely nothing to do with what people on the ground were seeing, feeling and doing during the blow up. If you start your investigation from this point of view, it is almost impossible to imagine the chaos that unfolded on the lake just days before, or what it was like to be trapped within that chaos. In a learning-focused investigation, however, the whole point is to understand the perpectives of the people in the middle of the unfolding turbulence, not just the perspective from the air on a perfect day. The reason we care about the perspectives of the people taking action, is that we are trying to learn practical lessons for other people operating in a high-risk environment.

Ditching your tools

Let’s go back for a moment and look at what they ditched. Over the course of minutes, they let go of their gear and equipment, their means of transportation (canoe), communication (radio), and their last-ditch protection (a fire shelter).

This is noteworthy because firefighters have a history of hanging on to our tools for too long. Professor Karl Weick wrote about how firefighters did this on both the 1994 South Canyon Fire and the 1949 Mann Gulch Fire:

A small, but powerful similarity between Mann Gulch and South Canyon is that, in both cases, when people were fleeing the blowup and were told to drop their tools so they could move faster, some resisted. Several calculations suggest that this resistance may have cost them their lives (Report, 1994, p. A3-5). They would have been able to move 15-20% faster (Putnam, 1994) without their packs and tools. Firefighters are not the only people who are reluctant to drop their tools. Naval seamen on ships are trained to wear steel-toed shoes at all times and often refuse to take them off when they are ordered to abandon a sinking ship. Fighter pilots report being reluctant to eject from the “warm womb” and “cocoon” of oxygen in a cockpit that is out of control into a far more harsh environment. It is just as hard to drop shoes or an aircraft as it is to drop a pulaski and a pack.

At Mann Gulch, Dodge told his crew to “drop all heavy tools” 200 yards after they turned upslope. According to Sallee (1949, pp. 75-76) and Rumsey (1949, p. 103) people either threw away everything or nothing. Dodge in his testimony said he “didn’t know until later that they had discarded shovels and pulaskis” (1949, p. 118). Sallee reported that with the fire racing at them, smokechaser Harrison was sitting resting “and he still had his pack on” (Sallee, 1949, p. 88).

This same pattern was repeated at South Canyon. Some of the smokejumpers who deployed their shelters above the lunch spot, did drop their tools. But in doing so, they were struck by the enormous symbolic significance of what they were doing. One observed that putting down a saw was like running up a white flag (Rhoades statement); another (Petrilli), that the “Pucker factor” went up a notch (Report, 1994, p. A5-69).

What about those who didn’t drop their tools? If dropping your tools signifies you’re in deep trouble, keeping them may help you feel you’re safe. To hold onto your tools is to stay in control, to remain a firefighter rather than a victim, to appear calm. I’m still in it. This is not just an issue of symbolism since tools are needed to scrape an area clear before deploying a fire shelter. But the reluctance to drop tools may come from other sources such as economics, habits, avoidance of failure, predictions of fire behavior, and social dynamics. Equipment is expensive and jumpers, at least, are told repeatedly and early in their training to carry out everything that is dropped to them. Habits built up during training are much more likely to involve moving with tools in hand, rather than moving and discarding tools. People have no idea what it feels like to run and discard tools or even how to do it. Rhoades in his statement mentions that as he was running to escape the South Canyon fire he kept looking for a place to put the saw down so it wouldn’t get burned, a search which undoubtedly slowed his progress. In his words, “at some point, about 300 yds. up the hill....I then realized I still had my saw over my shoulder! I irrationally started looking for a place to put it down where it wouldn’t get burned. I found a place I it (sic) didn’t, though the others’ saws did. I remember thinking I can’t believe I’m putting down my saw.” These words have even more impact when it is recalled that, among the fatalities, firefighter #10 (Putnam, 1994) was found with a saw handle still in his hand. To discard one’s tools may signify more than giving up control, it may also be an admission of failure which, in a “can do” culture, is a devastating thing to admit.²

In case you get the impression this was specific to those two fires, Ted Putnam (investigator of the 1994 South Canyon Fire) wrote,

“Since 1990 [i.e. over the last 5 years] wildland fire agencies have lost 23 people who might have survived had they simply dropped their tools and equipment for greater speed escaping fires.”³

This is why it was so significant that Jess and Jamie let go of their gear, canoe, and a shelter.

During the Pagami investigation, when I was interviewing Jess about this moment, I noticed how she focused on what was happening in the operational environment and the actions she needed to take. She didn’t get caught up in the stuff Weick mentioned. She was not hung up on the “symbolic significance” of the canoe, or whether the the shelter would “help [her] feel [she’s] safe,” or what it meant for her identity or ego to lose her gear. She was ruthlessly focus on operational reality and the needs of the mission above all else. That’s a hallmark of resilient decision-making.

Innovating

After throwing a fire shelter away, Jess and Jamie shared a single shelter, treading water, locking arms, each using her free hand to hold the shelter down.

Some context: When you do fire shelter training, you practice deploying a fire shelter from different positions, and under different conditions. You even practice sharing a fire shelter—as firefighter Rebecca Welch heroically did on the 2001 Thirtymile Fire, when she shared her shelter with two civilians when their escape was cut off by the fire.

But the configuration these women came up with on the Pagami Fire—locking arms and drifting in the waves—this is something they invented on the spot. It was an innovation forced by the situation.

From plan-following to innovating

To recap, we’ve just seen how, within a matter of minutes, Jess and Jamie’s situation evolved from familiar, safe and straightforward to downright chaotic. Step by step, you can see how Jess’s decision-making evolved from

• clear and simple action, to

• taking the commonsense obvious alternative,

• experimenting within the familiar,

• experimenting with the unfamiliar,

• coming up with something innovative that nobody’s done or heard of before.

Each step of the way, there were common pitfalls that normally trap people. It’s pretty common to

• miss warning signs,

• delay changing course,

• block out unwelcome evidence,

• cling to your earlier assumptions,

• try to use the tools at hand (instead focusing on solving the problem, which sometimes means letting go of your tools).

Jess and Jamie avoided these pitfalls. They stayed anchored in their intent and in operational reality. And, in extreme DARCness, they maneuvered to safety.

You and I will probably never be in a canoe crisis like this one—so situation-specific lessons are probably not very useful. But we will definitely face DARCness, so it can be incredibly useful to see what the Pagami story can tell us about resilient decision-making.

1. Pagami Report, p. 11

2. Weick, K. (1995) South Canyon Revisited: Lessons from High Reliability Organizations. In T. Putnam (Ed.) Findings From the Wildland Firefighters Human Factors Workshop; Improving Wildland Firefighter Performance Under Stressful, Risky Conditions: Toward Better Decisions on the Fireline and More Resilient Organizations. Technology & Development Program; USDA Forest Service. Updated July 1996. pp. 43, 44.

3. Putnam, T. (1995) Findings From the Wildland Firefighters Human Factors Workshop; Improving Wildland Firefighter Performance Under Stressful, Risky Conditions: Toward Better Decisions on the Fireline and More Resilient Organizations. Technology & Development Program; USDA Forest Service. Updated July 1996. p.3.