Lessons Learned
“Safety
Zone” newsletter, July, 2004
Lessons Learned —
author, date unknown
One-Year Anniversary Letter
by Kelly Close, FBAN
Declaration on Cramer
Redactions, by James Furnish, April, 2005
FSEEE v. USFS, FOIA
Civil Lawsuit Order,
December, 2005
FOIA
Request to USFS, December, 2005
FOIA Appeal to USFS,
February, 2006
Management Evaluation Report
Investigation Team Information
Synopsis of the
Cramer Fire Accident Investigation
Causal Factors
Contributing Factors
Addendum
Factual Report
Executive Summary
Narrative
Background
(facts 1 - 57)
Preaccident
(facts 58 - 201)
Accident
(fact 202)
Postaccident
(facts 203 - 237)
Findings
Appendix A
Resources on the Fire
Appendix B
Cramer Fire Timeline
Appendix C
Fire Behavior and Weather
Prior Conditions
Initial Phase
Transition
Phase
Acceleration
Phase
Entrapment
Phase
Appendix D
Equipment Found at H-2 and the Fatalities Site
Appendix E
Fire Policy, Directives, and Guides
OIG Investigation
OIG FOIA Response,
February, 2005
2nd FOIA Request to OIG,
April, 2006
2nd OIG FOIA Response,
August, 2006, (1.4 mb, Adobe .pdf file)
OSHA Investigation
OSHA Cramer Fire Briefing Paper
• Summary and ToC
• Sections I-IV
• Sections V-VII
• Section VIII
• Acronyms/Glossary
OSHA South Canyon Fire
Briefing Paper
Letter to District
Ranger, June 19, 2003
OSHA Investigation Guidelines
OSHA News Release
• OSHA Citation 1
• OSHA Citation
2
• OSHA
Citation 3
USFS Response
OSHA FOIA Letter
Adobe PDF and Microsoft Word versions of documents related to
the Cramer Fire can be downloaded from the U.S.
Forest Service website.
|
Note: This document was
released as part of the Cramer Fire inspection file as a copy of a fax
sent from the OSHA Denver Office on July 12, 2001 - presumably to assist
the Thirtymile Fire investigation.
Guidelines for a Team Investigation of a Catastrophic
Incident
In July, 1994, fourteen firefighters died in the South Canyon fire near
Glenwood Springs, CO. The Denver Area Office was charged with the investigation
of the incident —an investigation that would result in a Notice
of Unsafe or Unhealthful Working Conditions to the U.S. Department of
Agriculture/Forest Service and the U.S. Department of Interior/Bureau
of Land Management. Each agency received two items in the citation, one
Willful and one Serious.
A "Fire team" was formed comprised of the Area Director, Assistant
Area Director, One Safety Specialist and one Industrial Hygienist. In
addition the team was augmented by the Deputy Regional Administrator and
other regional staff including representatives from Federal State Operations,
TEC/FAP, and Technical Support.
This report is designed to assist Region VIII teams in the investigation
of any future occurrences or catastrophes.
The Fire Team provided input which has been divided into four categories
— Communications, Equipment/Workspace, Team Builders, and Team Support
— and then subdivided into What We Did Right and What We Can Do
Better.
The Fire Team believes that through their investigation they have established
a successful protocol for future investigations of catastrophic events.
I. COMMUNICATIONS
|
| WHAT WE DID RIGHT |
WITHIN THE TEAM
Good communications are necessary within the group, especially between
Management and Compliance Officers. It works best to have a local
management contact and also one at the National level.
Requested and received information from the local District Office
of the investigated agency/employer.
Everyone on the team (Area Office and Regional Office staff) got
a copy of everything.
Be sensitive to the possible resentment from others within the
office who feel the “team” is being treated differently.
If internal dissatisfaction is noted, curtail it immediately to
avoid detrimental side effects within the organization.
WITH FAMILIES OF VICTIMS
Communicate with the families of the deceased. All Area Office staff
were aware that calls from those family members were to be answered
by a team member or staff member familiar with the case. The family
member should always reach someone to talk to.
Several letters were sent from OSHA to the families of the deceased
with an 800 # and information on the investigation. This was done
early in the investigation as a proactive initiative.
WITH THE MEDIA AND THE PUBLIC
The media was always handled by management.
A list of questions and answers were developed for the media.
The media was controlled from one location — the Area Office.
The Area Office worked as one when the press releases were issued.
Packets of information were prepared in advance for the anticipated
onslaught of requests from the public. This foresight proved to
be good planning.
WITH THE AGENCY/EMPLOYER
From the beginning and throughout the investigation, OSHA’s
credibility was reinforced with the investigated agencies with an
up-front approach. Nothing was released to the media without the
knowledge of the investigated agency.
OSHA admitted up-front that they were not experts.
OSHA management and investigators reached agreement on the questions
for interviews with others. |
I. COMMUNICATIONS — WHAT WE CAN DO BETTER
WITHIN OSHA
Be sensitive to each other’s needs. Assuming there is not immediacy
to a request could be detrimental to the investigation efforts. Upper
management needs to be notified if a request has not been promptly fulfilled.
Recognize the importance and significance of the incident early in the
process. If need be, push the issue of importance.
Get commitment from management for personnel resources to conduct the
project. Keep talking among team members and with the agency to avoid
wrong impressions or expectations.
Topography maps as audiovisuals detracted from the verbal presentation
at the National Office.
II. EQUIPMENT/ WORKSPACE
|
| WHAT WE DID RIGHT |
Be prepared with laptops, modems, printers, cellular telephones,
etc. The types of equipment needed will depend on the circumstances
and location of the incident.
Computerizing the citations and reports helped in making last minute
changes.
A separate office space was set aside for the sole use of the investigating
team. |
II. EQUIPMENT/ WORKSPACE —WHAT WE CAN DO BETTER
Assure that sufficient types and quantities of equipment are available.
For this investigation, additional cellular telephones, one for each team
member, would have provided an easier and time-saving avenue of communications
from remote locations.
III. TEAM BUILDERS |
| WHAT WE DID RIGHT |
THE TEAM
A lot of emphasis was put on the composition of the team. It is
recommended that all candidates considered be asked for their input.
Team members were selected based on availability, background, expertise,
and how well they complemented each other. Diversity can make a
significant contribution to the team.
Adjustments were made as necessary in the number of team members
and in the assistance they needed to do the work. The teams perceptions
of needed personnel and or staff assistance are probably correct
and their suggestions should be trusted.
it is important that the team members have trust and confidence
in each other and that the roles of all team members are recognized.
The team was Unified, both management and investigators.
The team members agreed that one couldn’t make promises and
not deliver.
THE PROCESS
The team assumed ownership of the case. Managing the process was
left to the investigators and presented to management for their
approval. CSHO’s were given the authority and flexibility
with limited control and/or monitoring.
The group held many meetings and concentrated on long-term outlook.
The decision-making process was flexible based on CSHO input and
their strong belief. No decisions were made in a vacuum, i.e., enough
information was available so that the right decisions could be determined
by management. Once a local decision was made, it was transmitted
to the National Office.
The team recognized the magnitude of the case and dealt with a
plethora of people — government agencies, local authorities,
national office staff, and congressional leaders — and emotions
— grief, anger, and power.
The case was well-prepared and presented by investigators, not
management.
Practice sessions of the presentation, complete with audiovisual
aids, were conducted. The presenters were flexible in changing their
tactics during practice. The team planned for the defense of their
position in preparation to counter possible rebuttals from the National
Office.
THE OUTCOME
The was a common goal for both the Area Office and the Regional
Office and the specific roles were all in tune with the projected
outcome.
The closing conference was totally controlled and handled by the
team.
The team followed through after the citation/abatement assistance
to assure continuity of OSHA’s intent. |
III. TEAM BUILDERS – WHAT WE CAN DO BETTER
THE TEAM
The team needs to be comfortable with each other’s basic philosophy
and level of commitment. In this investigation the Area Director assumed
a larger role on the team, substituting himself for another member. All
team members must totally believe in their work and remain committed to
it.
THE PROCESS
Use a timeline and establish a review process of the proposed violations/citations.
Determine who will review and how many reviewers are necessary.
IV. TEAM SUPPORT |
| WHAT WE DID RIGHT |
The team discovered that “Fear of Failing” is a factor,
but with management’s support and total commitment the team
was able to discourage the “what if” scenarios. This
commitment and support motivated the team members.
Additional funding was anticipated and made available by the Agency
for the team to make countless trips to the worksite as well as
travel to visit the families of the deceased and to the National
Office.
Management empowered the team with as much time as they needed to
focus on the incident and to process a well-prepared Willful and
Serious case. The process from start to finish is estimated at a
staggering 1,000 hours per CSHO and travel costs totally over $11,000.
The Regional Office provided guidance rather than directing or
mandating orders to the team
The Regional Office ran interference with any opposition and acted
as the conduit to the National Office. Feedback from the field was
available on a daily basis.
The Regional Administrator played a major role in communicating
with the National Office and assuring that the investigation continued.
In this investigation of Federal Agencies, the lack of Solicitor
involvement worked our advantage.
OSHA hired an expert about ¾ of the way though the investigation.
It worked on this case, but it may or may not work depending on
the incident. Know what you want the expert to do. Be prepared to
clearly identify the amount of work you want the expert to perform;
it will cost less.
Just as the Area Director needed to assert himself as a team member,
it was also necessary for the Deputy Regional Administrator to provide
his services from the regional Office for the team. He was successful
in using his influence to attain information and establish important
contacts. |
IV. TEAM SUPPORT — WHAT WE CAN DO BETTER
The team initially did not receive information or full cooperation from
other agencies or National Office personnel. This was an organizational
issue as well as a political issue. The team fells that having a contact
person with clout will make the difference. In this investigation the
“clout” was the Regional Office, specifically, the Regional
Administrator and Deputy Regional Administrator.
SUGGESTIONS FOR FUTURE TEAMS
1. The team should decide early in the process if the final product
is expected to be a citation, a report, or a combination of the
two.
2. Sometime during the investigation, the team should decide if
it will be a coordinated final product.
3. The team should discuss the need for legal support.
4. For reference purposes and as a statistical measure, track
the time spent by each team member as well as the travel funds expended. |
CONCLUSION
1. The success of OSHA’s investigation and the results of significant
findings from the South Canyon Fire can be attributed to a remarkable
team of individuals—
2. Good communications are essential throughout the process with everyone—
team members, office staff (Area, Regional, and National), other agency/company
representatives, family members of deceased, public, and media.
3. The Agency’s support in committing personnel, allocating equipment
and funds, and allowing the time to do the job well, contributed to the
team’s success.
4. A successful team is the result of:
a. good planning
b. a strong belief in the purpose and goal, and
c. the versatility to make adjustments when necessary.
5. A workable team should consist of a diverse group of individuals.
Each member of the team should have the opportunity to make a significant
contribution.
|
