1In the Heat of the Moment
At 4 p.m. on August 5, 1949, Wagner Dodge and his crew of sixteen parachuted into the remote Montana wilderness at Mann Gulch to combat what seemed to be a routine forest fire. By 5:56 p.m., all but three of the firefighters were dead, fatally burned—then the worst disaster in the history of the U.S. Forest Service and one caught memorably by Norman Maclean in Young Men and Fire.
Forty-five years later, on July 6, 1994, Donald Mackey was helping to oversee a team of forty-nine firefighters spread out on Storm King Mountain in Colorado. Some of the group had parachuted onto the mountain that day; others had come by helicopter, still others by foot. Again, it looked like a routine fire, and again, the fire proved that it is always a mistake to treat any backcountry blaze as routine. By four o’clock in the afternoon of July 6, the Mann Gulch disaster seemed about to repeat itself.
In both cases, bad luck and a fatal confluence of environmental factors contributed to the flaming ambush of the firefighters, but individual decisions were critical in each instance. At Mann Gulch as at Storm King, those most directly responsible on site faced a sequence of decision points during their fateful hours in the fire zone, and their decisions at those moments helped take their teams to the brink of disaster and beyond.
Wildland fires are a special circumstance, and wildland firefighters— the men and women who parachute, helicopter, or trek in to fight them— a special breed. But while the conditions are unique, the experience of those who fight fires in the outdoors has much to teach us all about decision making indoors, especially when there is little room for error or delay. The go points their crew leaders reach and the consequences that follow are unusually clear-cut and consequential for the goals of the enterprise. And like so many critical business decisions, fire decisions brutally punish those who do not keep both the big picture and small detail well in mind.
The blaze that raged over Colorado’s Storm King Mountain on July 5 and 6, 1994, in what has come to be known as the South Canyon fire, has been the subject of extensive official study and secondary analysis, including one by Norman Maclean’s son, John, who chronicled the fire’s course and the efforts to combat it in Fire on the Mountain. Thus, we have an exceptionally well-documented record of the decisions taken by those responsible for the firefighters on the mountain.
In analyzing the record, I do not seek to criticize anyone involved or to affix blame for the disaster that occurred on any one individual. Whether they survived the blaze or not, the wildland firefighters who assembled on Storm King Mountain were heroes: they placed themselves in harm’s way to protect others, and some paid the ultimate price. But firefighters also feel it is their duty to unflinchingly examine past tragedies to determine what decisions went wrong so they can prevent similar calamities in the future. In that spirit and from their bravery come enduring lessons in the art and science of decision making whatever the zone.The Basics: Safety, Speed, and Suppression
In attacking wilderness fires, firefighters traditionally form into crews ranging from three to twenty members. The crews are rapidly deployed, combining with other crews to combat larger fires and then just as quickly breaking up and redeploying to other incidents. As might be expected of their organizational chart, crew leaders operate both collaboratively and independently, but during multiple-crew blazes, as was the case in the South Canyon fire, one individual of necessity should assume clear and authoritative responsibility. As we shall shortly see, that did not happen on Storm King Mountain.
“On any incident, large or small,” states one of the basic fire service manuals, “the Incident Commander has ultimate responsibility for the effective and safe execution” of all aspects of the attack. The commander’s duties place a premium on ensuring that decisions optimally contribute to the three primary goals of firefighting: safety, speed, and suppression.
Always, the premier criterion for decision making by fire crew leaders and incident commanders is the safety of their team. Even though physical peril looms large whenever crews are called in, fatal injuries are no more tolerable in firefighting than is fraudulent accounting in business or bogus stories in journalism. Yet since risk is always present, wildland fire leaders must be able to appraise it and take appropriate steps toward mitigation.
The second criterion for crew leaders and incident commanders is speed. Firefighting is a world of decision urgency. Hesitation and equivocation can do more than delay a solution: they can radically compound the problem. In product markets, the short term can be months; in stock markets, days; in fire zones, hours or even less. A 10-acre fire—small potatoes in the wildfire playbook—if not quickly suppressed can explode in minutes into a 1,000-acre conflagration. “Make sound and timely decisions,” the official firefighters’ manual exhorts, with good cause.
The final criterion for decision making in a fire zone is a set of technical considerations to actually suppress the fire: How many firefighters are required? Where should a fire line be constructed? What aerial reconnaissance is needed? On such technical calls can hang the fate of both the zone’s natural resources and the men and women who seek to preserve them.
Winding around all these matters and never separate from them are the shifting conditions of the wilderness fires. It is not in the nature of blazes to sit still, and each new shift in the fire can create new and dangerous microclimates—powerful winds, intense heat—that further complicate suppression. An incident commander or crew leader who makes the right choices, handles them quickly, and anticipates correctly where the fire might suddenly go and where his crew should subsequently be achieves the primary purpose of the business: “fight fire aggressively but provide for safety first.” Make the wrong choices, make them too late, and all hell can break loose.When “Can Do” Is Not Enough: Preparing for Decision Making
Wildland firefighters often assume leadership roles with little warning, in venues that are always new. Military leaders, of course, are called to do the same: freshly commissioned officers commanding soldiers in combat, for example, or seasoned officers taking troops onto an unknown battlefield. But unlike graduates of the military academies or war colleges, where leadership decisions have a central place in the curriculum, newly appointed wildfire incident commanders traditionally have taken charge with little or no formal preparation in leadership decisions. Indeed, prior to the South Canyon fire, the responsible federal agencies offered virtually no coursework in how to make decisions when lives depend on them.
Poor preparation predictably leads to poor choices. Consider one large adversary of good decisions: overconfidence, a moment when a responsible decision maker believes that a decision outcome is more likely than the factual situation would predict. Business studies have found that excessive audacity is most prevalent when managers face decisions on products and markets with which they are least familiar. In one such study, two researchers examined confidence among product managers of small computer software and hardware firms when they introduced radically new products to the market. The more pioneering the new products—and thus the less familiar the market—the more the product managers were likely to view the prospects for success through rose-colored glasses.
Firefighters constantly forced to make snap decisions in unfamiliar terrain face the same challenges. The less they have been prepared for a responsible decision-making role, the more a natural can-do attitude takes over. Without a pool of experience to back them up— experience in firefighting and in decision making—incident commanders sometimes latch onto a flawed firefighting strategy, certain that “we can make it work.” In the rapidly changing world of a racing fire, a can-do attitude is both essential and potentially dangerous.In the Heat of the Moment: Acute Stress and Decision Making
Wildland fires can reach 2,500 degrees Fahrenheit, race forward at speeds up to 25 miles per hour—a gold-medal speed in the Olympics’ 100-meter event—and leap overhead without warning. At their most dangerous, such fires are said to “blow up,” an inflection point when they acquire a manic momentum of their own. Like avalanches and tornadoes, a blowup is one of nature’s most terrifying spectacles, one reason tension is ever present in a fire zone. For crew leaders and incident commanders, those who carry personal responsibility for the lives of others, the resulting tension can become acute. The more severe the stress, the less optimal decisions are likely to be just at a time when they are becoming most consequential.
Research confirms that individuals under time pressure or performing simultaneous multiple tasks are more prone to indulge in poor decision making for a host of reasons including a reluctance to search for relevant information. Studies also demonstrate that the adverse effects of underpreparation on decision making become most pronounced in the most severe conditions. In short, the two enemies of optimal decisions—poor preparation and great stress—are particularly pernicious when combined.
In studying urban firefighter captains and lieutenants, Fred Fielder found that while seasoned officers actually improved their performance under the stress of a fire, less prepared ones went in the opposite direction. The same is true of responsible officers on aircraft carrier flight decks. According to research by Karl Weick and Karlene Roberts, the officers were more likely to commit errors during stressful landing episodes when their collective mindfulness and mutual heedfulness were insufficiently developed or became impaired by the rush of events. John Salka, a battalion chief with the New York Fire Department, spoke from his own twenty-five years on the front lines when he urged fire managers to pay particular attention to their inner voice—if well educated—when taking decisions under stress. For “making the right call when the heat is on,” Salka writes, “intuition is really your subconscious trying to offer up the benefits of a lifetime’s worth of experience.”
Drawing on extensive investigation of those facing difficult decision points, Gary Klein concluded likewise that intuition—if well honed and informed by experience—improves decision making, especially in the heat of the moment. Note the “well-honed” and “informed” part of that. Decision experience helps one compile a mental reference library that sends up a special alert when conditions look bad. It is what you call on when the ground is shifting beneath your feet and there is little time left to reason things out for yourself and for those depending on you. Unfortunately, in South Canyon on July 6, 1994, well-honed and informed decision capacities were in short supply.Who’s in Charge? Ambiguous Authority and Leadership Decisions
The decision-making burden on fire leaders is made even greater by three organizational factors that are especially prevalent in combating wildland blazes. First, crew leaders guide a workforce that is largely seasonal since fires are by far the most common in the dry summer months. Second, leaders are required to collaborate with other agencies over which they have no control. And third, as fire crews meld into temporary amalgamations on larger blazes, crew leaders and incident commanders find themselves working with, reporting to, or instructing other crews and leaders whom they have never previously met or barely know.
All three sources of ambiguous authority work to undermine optimal decision making. The seasonal crews are often underdeveloped as teams. Although they are forced to work together in ad hoc organizations, the various parties also bring self-interested agendas to bear, and crew leaders and incident commanders must coordinate unknown quantities and unfamiliar personalities. (Think of an orchestra conductor taking the podium for the first time in front of a brass section from Cleveland, strings from San Francisco, reeds from Denver, and percussion from Seattle.) The weak relations among the various parties also tend to result in information hoarding as much as sharing. Incident commanders are sometimes called upon to make critical decisions based on less knowledge than is available within the teams themselves.
Add the parts up—a reduced flow of information to the fire leader, a weakened commitment by the leader to exercise authority, and diminished team compliance with the leader’s instructions—and you have the ready makings of a decision crisis. All that is needed is an unpredictable fire to spark it.The South Canyon Fire
“Okay, everybody out of the canyon!” Don Mackey radioed to his beleaguered firefighters. For hours, they had been clearing a corridor on Storm King Mountain to thwart a spreading wildfire. Now that path had become the crew’s only way out. Eighteen people were sprinting for their lives. Could they reach safety?
The summer of ’94 baked central Colorado in a heat rarely seen on the mountains. Drought dried out the earth, leaving it gasping for moisture and ripe for ignition. On the morning of July 2, Storm King Mountain began to burn. By July 4 the fire had spread to perhaps 3 acres, a relatively small and slow-moving blaze and one, local officials decided, that could wait while they put out dozens of more serious ones.
Not until the morning of July 5 did the first firefighters venture up to contain it. Less than thirty-six hours later, fourteen of them were dead. Elite members of a caste of itinerant warriors who battle in hard hats and chain saws against one of humanity’s oldest enemies, these ten men and four women were consumed by a wall of fire that moved faster than the fastest could run.
The crisis on Storm King Mountain was not only a natural disaster; it was also a decision failure, a result of miscalculation. Firefighter Don Mackey made several of the big decisions—some good, others less so, at least one of them heroic—but Mackey was not acting alone. He was a product, arguably a victim, of a system that had failed to teach him how to make good decisions.
For years the agencies responsible for wildland firefighting had focused on fire behavior rather than human behavior, akin to a business that concentrates on engineering rather than customers. Even when earlier fire tragedies had hinged on human error, the recommendations sent forth from them were usually technical ones. The result was that Mackey and others hit the mountain with state-of-the- art gear but scant training in how to make urgent choices under intense pressure.
As in most disasters, no single decision was responsible for the outcome at South Canyon; instead, it was the result of a cascading series of smaller ones. One of the tragedies of the conflagration is that the errors could have been avoided. Excessive optimism, untested assumptions, unheeded warnings, poor intelligence, failure to clarify authority: at Storm King, nearly all the great enemies of good decision making were present in abundance. The “collapse in decision making” was “almost automatic,” a U.S. Forest Service researcher argued afterward.From the Hardcover edition.
Excerpted from The Go Point by Michael Useem. Copyright © 2006 by Michael Useem. Excerpted by permission of Crown Business, a division of Random House LLC. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.