Continuous Improvement

in Decision Making for

Large Fire Management
Additional information pertaining to the elements of this guide can
be found on the Lessons Learned Center website at:
http://www.wildfirelessons.net
 Introduction

T he fire environment is a dynamic, continually changing system influenced

by climate change, weather, fuels, vegetation and humans. The
intersection of these factors drives wildland fire impacts, responses and
reactions. Recent years have seen an emerging phenomenon referred to in variety
of ways including “Mega Fire”, “0.25% Fires” and “Fires of National Significance”;
regardless of the moniker, the trend is real and has dire consequences. These
fires are larger, more dangerous and more expensive than ever before. This small
number (20-30) of “mega” fires was the scene of all the fatalities on U.S. Forest
Service jurisdiction in 2008. This percentage of fatalities has steadily climbed
since 2005 when there were no fatalities on these types of fires. In addition to the
increase in lives lost, the average suppression cost for these fires now exceeds $500
million annually. Other trends are emerging as well. Overall, fatalities and acres
burned are increasing, and the number of fires exceeding 100,000 acres is five
times more than it was just ten years ago.

The wildland fire community has at times employed the principle of over-
whelming mass, (the precautionary principle) which assumes there will be
adequate resources to fully execute the chosen strategies on all fires. The notion
that each fire is a separate and independent event is one of the most deeply
engrained mental models. The precautionary principle drives many decisions
and basically states: in the absence of science and an expectation of differing
outcomes, leaders will choose the most conservative approach to a problem.
Another way to view this would be - managers will order resources ‘just in case’.

Forest Service leadership at all levels, along with partners, stakeholders and
cooperators has taken up the challenge of improving both decisions and
management of these colossal fires. This should be viewed as a journey and not
a destination. Like any journey there are a number of steps. The first step in the
process was to deconstruct and study fires to discover opportunities to change
outcomes. It was recognized decisions were driving outcomes and with improved
decisions, leaders could expect better outcomes in safety, fires impact on the land
and cost. Science-based, decision support tools have been improved and will be
deployed to assist leaders in making better and more informed decisions. These
tools do not replace leadership or excellent judgment.

A select group of forests were chosen for the test bed or to pilot this improved
management model. These forests, sometimes referred to as “at risk” forests,
display several unique characteristics which led to their selection. High quality,
local leadership with the ability and determination to be on the cutting edge of
new technology was a prime consideration. Other factors included climatology
and fire history. Ideally, the opportunity to pilot an improved set of tools and
actions on these dangerous and expensive fires will be embraced on these units.

This guide is designed to assist you in the journey of leading wildland fire complex
incident management into the 21st century.

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NOTES:

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 Common Approach

Mental Models
Mental models predispose people to act or react a particular way. Another way to
think about mental models is that they are perceptions. They do not have inherent
value and, at times, keep people safe; at other times they may cause a reaction or
action that is viewed as negative. An example would be: strangers can’t be trusted.
This model likely keeps people out of harm’s way; sometimes it also precludes
people from meeting an interesting or helpful person. When mental models are
not based on fact or reality, they can lead to undesirable outcomes. Fear often
arises out of mental models and fear begets strong reactions.

Wildland Fire Disaster Mental Model

In wildland fire, a number of common mental models drive decisions. Some of the
most common are:

• Fire is bad;
• Airtankers put fires out;
• All fires can be put out if you just try;
• There are unlimited fire fighting resources;
• An incident management team has 50 members;
• Line officers don’t know fire;
• Incident management teams don’t listen; and
• The community will not tolerate any more smoke.

This short list of mental models was captured at various locations and with a wide
variety of groups around the country.

This list, by no means, should be considered exhaustive, but rather representative.

Breaking the Cycle

Creating a “shift” in mental models will often
be necessary in order to affect a change in the
approach to wildland fire. This will require
explicit action to engage people and their
mental models. One way to accomplish this
would be through an exercise designed to
identify and address mental models. Once
these models are identified, and the root or
basis is determined, a shift becomes possible.

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 Common Approach

Converting Fears to Risks

Every change brings risk. No matter what we do, whenever we take action we
cause things to change, and change, of course, moves us from the familiar to the
unknown.

Some actions - deciding where to deploy resources on a large, fast-moving fire,

for example - set in motion complex chains of events that are easy to recognize as
carrying risk. Other, smaller actions - like pressing the “send” button on an email -
may not seem to carry as much risk. However, depending on the content of the
message or even its context, the risk can be just as great. So the risks of a situation
are often less related to how large or small they appear, and much to do with their
content and context.
It’s important to draw a distinction here between fear and risk. Fear is an emotion,
an uneasy feeling about something that might happen in the future. Risks, by
contrast, are the possible outcomes of current actions. For example, a person
about to give a presentation to a large group may feel a general sense of fear, but
the risks of “what could happen” are a lot more specific: people could laugh (for all
the wrong reasons!), the speaker could lose credibility, he or she could forget what
they wanted to say, and so on.
A general (and normal) sense of fear that individuals and groups experience in
the face of a new direction or change can almost always be converted into risks,
and it’s worth the time to do so. This is because fear, living generally below the
surface of people’s thoughts, is very difficult to access and deal with “head on.”
Acknowledging risks, however - because they are specific - is a useful starting
point for change that can be conducted safely, anticipating possible unwanted
outcomes.
Just as there are possible hazards associated with taking a new direction, so also
are there risks to keeping things the way they are. Usually the longer something
has been done the same way, the less likely it is that people will remember why
the actions were originally taken, or what problems were being addressed when
the (then-new) direction was being proposed. For example, many checklists have
been put together over the decades to free up decision-makers to concentrate on
a larger picture and make sure that no essential step has been forgotten. However,
when checklists proliferate they tend to block the very awareness they were once
developed to facilitate.
The practice of converting fear to risk can be developed individually or in a group
context. By applying the same process used in your field session, you can go
underneath almost any fear and make it actionable, transforming the power of
fear into a resource that will help you make clear decisions and give you a range of
options that might not be seen otherwise.

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Common Approach

Operational Risk Management

Operational risk management is very specific, science-based process for defining,
analyzing and managing risk. Risk management is a profession and has more
“depth” than the typical techniques used by the wildland fire community to
identify and mitigate hazards. This system relies on a shift in culture(s), from rules
and punishment, to operational resilience.
The risk management element of this safety culture system uses:
• Risk Assessment – where all risks are determined. This determination not
only identifies the risks, but quantifies them in terms of probability and
consequences.
• Risk/Benefit/Analysis – once the risks are clearly identified, analysis is
performed to assess the potential trade-offs between risk and benefit.
• Operational Risk Management – a continuous feedback loop occurs once
the activity begins, questioning the assumptions and analysis, reporting near
misses, and attuned to error detection.
This type of system enables leaders to overcome potentially dangerous mental
models such as the continuation of efforts, i.e. there has been an “investment” in
this operation therefore the action must continue. The current system in use does
not often assess the activity in terms of should it be started or completed, but
rather views it from the perspective of “mitigate the hazards and continue.” This
system requires leaders to make risk informed decisions.
A simplistic contrast of these two approaches can be illustrated in a typical mop-
up scenario. The current approach would be to identify the hazards such as
snags, rolling rocks and stump holes. These would be discussed, flagged and the
operation would proceed. Additional measures may be weighing the risks and
benefits of mop-up. If the likelihood of escape is low (because of fuel conditions,
fire behavior, etc) then explore other alternatives to mop-up such as posting
lookouts instead of assigning firefighters to do a job unnecessarily. This could be
more effective when compared to extended duration of exposure to firefighters
for limited benefit to deplete a small chance the fire might reignite in that area.
Operational risk management would go beyond the identification of hazards and
would analyze the probability of escape, quantify the hazards of dealing with an
escape and weigh these findings against the probability that mop-up would be
successful.
It should be apparent in this analysis, the application of operational risk
management can be a powerful and effective way to improve fire fighter safety
and provide leaders with a set of tools for risk-informed decision making.
This system requires training and practice and will not be implemented without
both. The National Incident Management Organization is being trained and will
employ these principles on fires where they are assisting.

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 Decision Support

Wildland Fire Decision Support System

Over the past several years wildland
fire agencies have been working
aggressively to deliver a new system
to support agency administrators and
fire managers in making improved,
fire management decisions. This
system, the Wildland Fire Decision
Support System (WFDSS), is
structured to provide access to a
suite of decision support analysis
tools, document fire management
decisions, and provide a long-term
operational plan as needed.
WFDSS is constructed as a web-
based system but can also generate a
variety of standard or custom reports.
One report, the Decision Analysis
Report (DAR), represents the compilation of all WFDSS subsection information into
a single report that becomes the formal decision documentation for the incident.
This report was prototyped in 2008 as a replacement for current decision analysis
products.

Key Decision Log (KDL)

The Key Decision Log (KDL) is one of a suite of evolving tools that make up the
Wildland Fire Decision Support System (WFDSS). It allows Agency Administrators,
Fire Management Officers, incident management organizations and other fire
leaders to accurately record, in near-real time, implementation decisions that
directly and indirectly affect the management of a wildland fire.
Identifying best practices and promoting organizational learning is the
cornerstone of a High Reliability Organization (HRO). By understanding how
and why decision makers select a specific course of action, the complexity of an
incident can be better understood and transparently communicated through
agency channels. It can also be used as a real time reference to past decisions that
promotes consistency during team transitions and key decision points along the
life of an incident. The KDL facilitates high reliability and continual improvement
by allowing practitioners and researchers to recreate the sequence of events that
occur over the life of an incident. These patterns can then be used to develop
Lessons Learned that embrace the fundamental concept of Doctrine by sustaining
best practices and identifying and eliminating unwanted decision traps.

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Decision Support

Delegation of Authority & Leaders Intent

Delegating authority is about assigning and sharing one’s own authority to take
action, with subordinate personnel. Policy requires an Agency Administrator
(AA) to issue a Delegation of Authority (DOA) letter to an incoming Incident
Commander (IC) to manage an incident within their administrative responsibility.
Circumstances may arise when a verbal delegation is appropriate, i.e., immediate
need for leadership to deal with a serious injury or fatality.

Document these delegations in a Key Decision Log. Issuing a brief DOA, (takeover
date and time) with separate attachments covering leader’s intent and the WFDSS
Decision Analysis Report, allows an AA to modify leader’s intent and priorities
without having to reissue a formal delegation.

At the heart of every briefing is the purpose or objectives of the assignment or

“Leader’s Intent.” If followers know what the goal is, they will be able to determine
what they must do to reach it, even if the leader is absent. Leader’s Intent consists
of three parts:
• Task – how the Leader envisions achieving the objectives, what has to
be done.
• Purpose – illustrates why tasks are being done (sense-making).
• End State – expected results, the goal, what the task should look like
when completed.
The AA and IC should meet to discuss: leader’s intent, decision making parameters,
during incident review process, approval protocols, collaboration processes,
documentation of shared decision making and responsibility, strategic alternatives,
cost management, etc. This process is complimentary to the normal IMT in-brief.

During Incident Review (DIR)

The goal of the During Incident Review is to improve decisions expected to
drive successful outcomes. The intent is to build trust and understanding by
creating a solid working relationship to allow for intervention, course corrections
and prevent surprises while establishing clear expectations for how to make
risk-informed decisions on fires. The During Incident Review is a continuous
learning opportunity for both the Incident Management Team and the Agency
Administrator and contributes toward building a more highly reliable organization.
The During Incident Review is a meeting held at various times throughout the
duration of an Incident. The Incident Commander and the Agency Administrator
can sit down and spend quality time together. The During Incident Review
provides a forum for important interactive discussions. The intent of these
meeting(s) and discussion(s) is to build trust and understanding by creating a
solid working relationship. Used well and often, these meetings will allow for

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 Decision Support
intervention, course corrections and prevent surprises. The Agency Administrator
is able to honestly describe his/her issues, worries, interests and the IC, in turn,
is able to describe probabilities, concerns and predicted results. It takes time
together to build trust, honesty, predictability and reliable results (between the
Host Unit and the Incident Management Team).

Predictive Services
Predictive Services was developed to
provide decision support information
needed to be more proactive in
anticipating significant fire activity and
determining resource allocation needs.
Predictive Services consists of three
primary functions: fire weather; fire
danger/fuels; and intelligence/resource
status information. Predictive Service
staff units are located at the National
Interagency Coordination Center (NICC)
and the Geographic Area Coordination
Centers (GACC’s) across the country.
Weather: Meteorologists analyze a
variety of weather products and services
to provide briefings and outlooks for
current and forecasted conditions and, in
some cases, provide spot weather and smoke forecasts. A number of innovative
products and tools have been created to help fire managers assess fire potential
and high risk areas.
Fuels and Fire Danger: Wildland Fire Analysts, stationed or detailed at some
locations, provide predictions and condition reports on fuels, fire danger, fire
behavior, fire occurrence statistics, and resource needs.

Intelligence: The Intelligence Section provides fire management personnel,

incident managers, firefighters and support staff with access to current intelligence
on preparedness levels, fire situation, resources, mapping and satellite imagery,
climatology, preparedness levels, resource availability, rotation schedules, and fire
potential information.

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Decision Support

NOTES:

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 Opportunity Recognition

Danger or Opportunity: Examining how We

Perceive Large Fires
Good Situational Awareness (SA) is the first step in the decision making process.
This is based on observing and communicating what is seen, heard and felt. This
allows the match of perception of the environment as closely as possible to the
reality of the environment. This is a complicated process as humans tend to make
decisions based on perception (observation + communication + emotion) and
not necessarily on reality. Good SA equals good perception and ultimately good
decisions.
A common perception of fire managers and line officers is that unwanted large
fires must be aggressively suppressed. Simply put . . . Fire = Danger. Any other
course of action, its felt, will sail into a sea fraught with failure and promote a
negative public reaction. Many feel it is important to be perceived by the public to
be doing everything possible to deal with the unwanted, unplanned fire (danger).
This is described in literature as the “Precautionary Principle.”
An unwanted fire in the wrong place at the wrong time is truly a danger.
Recognizing this, the Agency has designed an aggressive and effective approach
to initial attack and will continue to aggressively suppress problematic fires.
Ironically, the ability to successfully suppress the majority of the fires that occur, has
allowed a drift into complacency in decision making by automatically engaging
the suppression machine before mindful decisions about the effects of the fire are
made.
Often fire is perceived to be a danger simply because it triggers dramatic change
and disrupts our lives. Therefore, it is easy to choose to “fight” the fire through the
application of overwhelming mass. The language used reinforces this behavior.
There is a battle to contain the wildfire that is “burning out of control” and
“threatening” the forest. The reliance on abundance of aircraft and ground crews
gives the impression it is possible to sail into safer waters, away from negative
public perception, away from danger. The perception is as follows . . . more fire =
more firefighters.
However, there is now a more broadly held understanding of the reality of fire. Fire
is important and necessary. Almost all of the vegetation and ecosystems in United
States are fire adapted and/or fire evolved. Fire belongs here. Fire has always been
and will always be a part of the landscape. Native Americans used fire regularly.
European settlers brought a negative perception of fire which is still pervasive in
this country. The longer fire is out of the equation, the greater the impact when it
is included. That is reality. Fire is not always good, fire is not always bad. It just is.
Like rain, too little or too much can be harmful.
But, what if fire was perceived as opportunity? What if this latest escaped fire was
seen as an opportunity to finally allow fire on the landscape, to reset the ecological
clock. This fire could allow for a more “fireproof” community which no longer had
to stop worrying every summer about evacuations. This fire could allow stronger
bonds with neighbors and bring the community together.

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Opportunity Recognition
Imagine if every fire was
viewed as an opportunity to
think carefully about when,
where and how much risk the
lives of our young men and
women should be exposed
to? Often the risk from
the values to be protected
(infrastructure, threat to an
endangered species, historic
cabin, etc) is transferred
directly to the firefighters and
into the cockpits of aircraft.
What is truly a greater danger
(risk); a closed highway or
100 firefighters and multiple
aircraft working to keep the
highway open?
This leads to a simple question
when looking at a fire; is the
danger real or perceived; is
aggressively suppressing the
fire truly worth the risk?
An excerpt from a recent article in the December edition of the Journal of Forestry:
“External Human Factors in Incident Management Team Decision Making and Their
Effect on Large Fire Suppression Expenditures” accurately depicts the decision
dilemma.
“Sociologist W. I. Thomas wrote, “If men define things as real, they are real in their
consequences” (as cited by McHugh 1968, p. 7). Because perceptions are reality
in a person’s mind, decisions are made based on those perceptions. This means a
tendency toward risk aversion and a shrinking pool of midlevel fire managers may
continue, as will increase costs, unless the perception is changed.”

Basing Strategy and Tactics on Recognizing

Opportunity
Traditional wildland fire strategies start with an anchor point and then require an
ever-increasing insertion of people and equipment until either a direct or indirect
line is completed. This traditional strategy is based on Agency Administrator
and incident managers’ perceptions of threats (dangers) and rarely considers the
naturally pre-determined, and possibly inevitable, path of the fire.

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 Opportunity Recognition
Consider if a strategy was developed based on hot, dry and unstable weather,
Type I crews and aviation resources being in short supply and recognition that the
frightened public is reacting emotionally to their perceptions of the danger of fire
and smoke? Consider whether this strategy would not transfer risk to firefighters?
And, whether the strategy developed would not saddle the taxpayers with the
financial burden of a multi-million dollar fire? What would that strategy look like?
Additionally, what if the strategy saw fire as an inevitable occurrence and the
fire was managed with the view that considered the next fire as pre-determined
and inevitable. This more enlightened strategy would recognize the role of fire
in shaping vegetation and ecosystems, yielding a fire management strategy that
considered all risks, opportunities and outcomes, rather than just “fighting the fire,
or battling the flames.

A Large Fire Story

Initial Attack of the Big Pine Fire was unsuccessful. The IMT was able to protect
the nearby community but nine days later only 40 percent of the fire is contained
and the remainder is in rough terrain. Rain is 4-6 weeks out. The fire is not going
away anytime soon and, frankly, a few Red Flag days could make the situation
worse. The fire could make another run at the community if several factors line
up. Six hundred firefighters are committed to the incident. The cost to date is
$6 million and the daily cost rate is $900,000. Smoke is impacting the adjacent
National Park. The Governor has called, twice. What is your perception; one of
danger or one of opportunity?
Either way, now is the time to develop a very clear and succinct strategy. Identify
the values at risk. Identify the dangers and then look at the opportunities. There
are a number of non-traditional strategies that may offer opportunities.

Recognizing Opportunity
Flashing back to the Big Pine Fire, why wait for the inevitable Red Flag conditions?
Knowing overwhelming mass is going to be ineffective in the rough terrain and
knowing an alignment of conditions will create a negative outcome, then where
are the opportunities? Where could and should the appropriate amount of force
be applied? Where are the trigger points that can prevent the next run at town? Is
the insertion of small mobile assets to significantly alter the undesirable scenario
possible? Are there options to check, direct and delay with minimal firefighter
exposure? Just because the flanks can be secured, will it make any difference to
the community?
Scientist and analyst have made great strides in technology and predictive services
in the last few years. Decision makers now have the ability to identify windows
of opportunity. Surgically applying burn-out operations, securing a key piece of

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Opportunity Recognition
ground or expanding and contracting suppression resources, to be in the right
place at that right time, is now a realistic approach.
Traditional burn-outs have an anchor point and a tie-in point. This common-sense
approach is safe and effective and has been used for decades. It works on the vast
majority of fires. Some fires, especially the large, long duration fires may warrant
unanchored burn-outs that target fuel reduction and fire behavior mitigation
and not necessarily perimeter containment. These actions can mitigate fire and
suppression impacts, ensure community protection and can be done under the
most favorable conditions. This is in contrast to waiting on the fire while fuels
become drier and the probability of experiencing Red Flag conditions is near 100
percent.
Choose the ground to hold very carefully. Remember size is less important than
positive or negative impacts on the landscape. Place fire on the ground on fire
management terms not on the fire’s terms. Don’t wait until the fire is at the edge
of what is at risk; don’t be reactive. Consider a well-planned night burn-out.
Timing can limit costly and often unnecessary “line prep” by finding the right
ground. If the land is under a different ownership work with the landowner to
achieve a reasonable objective, explain to the landowner the idea of opportunity.
Large fires often cost more than $1 million/day. Find a way to explain your
predicament to the land owner. It is after all, their tax money. Do a cost analysis, is
“buying” the good ground more cost effective? Run it up the decision tree and see
what happens.
Favorable fuels + good ground + Predictive Services = Opportunity
Heavy fuels + bad ground + reacting = Increased Firefighter Exposure
When developing a large fire strategy, plan for allowing ICS to expand and
contract as it was intended. Designate Trigger Points and Management Action
Points (MAPs) that are designed to activate the necessary resources/actions at
the right time and at the right place.
For fire ground decision makers, it is
important to view this one fire as a
small component of a much larger
puzzle: a puzzle that includes long-term
ecological impacts, as well as short-term
fears and perceptions, and is able to
recognize and act upon opportunity.

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 Social Networking

Community - Agency Interaction

A Joint Fire Science project conducted on Forest Service fires in 2008 explored
how community-agency interaction influenced the exercise of Appropriate
Management Response. This was evaluated from the forest, incident management
team and the community perspectives. As a result of the research, several
recommendations have been made with the hypothesis that initiating the
recommended actions will result in better understanding and support of fire
management activities. The recommendations included:
• Pre-season interaction with communities around fire-prone areas;
• Manage community and cooperator expectations before an event
occurs;
• More timely and widespread dissemination of information; and
• Better coordination and information sharing internally and externally.
Data collected in 2008 will be used to craft a survey that will be administered
in 2009 to a broader segment of the public in three, fire-affected communities.
This will allow for a systematic and comprehensively approach to assess public
attitudes about fire management strategies and tactics and also will help
determine if the above noted recommendations improved community-agency
interaction.

Network Mapping
Network Mapping is how we build a social structure made of nodes (which are
generally individuals or organizations) that are tied by one or more specific types
of relationships. In this case, we are interested in relationships or ties related
to wildfire. Nodes are the individuals within the networks, and ties are the
relationships between the individuals. There can be many kinds of relationships
between these individuals: work, social, family, common interests, etc. Social
networks operate on many levels and play a critical role in determining the way
problems are solved, organizations are run, and the degree to which individuals
succeed in achieving their goals. In its simplest form, a social network is a map
of individuals that serves as a visual tool to identify those whom with they
communicate and the type of relationships they have.
Visual representation of social networks is important to be able to see the
strengths and weaknesses of your communications. Seeing the people you talk
to and the relationships you have, laid out in a map, makes it obvious where the
bottlenecks are and where good communication flows.
There are two primary benefits of network mapping. First it can identify where
communication breakdowns are occurring between and within groups; and
second it can identify individuals with knowledge that might be useful, but are not
being tapped.

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NOTES:

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