USFS: Cascade Complex Accident Prevention Analysis released

Cascade Complex Accident Prevention Analysis

The Cascade Complex Accident Prevention Analysis is now released and posted on the web.

This report examined the circumstances surrounding three events:
The entrapment of two fire support contractors, implementation of the “stay in place plan” for the Cascade Complex Incident Command Post, and the decision to remain at that same ICP after the event.
The process used to review and investigate the accidents analyzed in the report may not be familiar to many of you.
The Accident Prevention Analysis (APA) process has several unique characteristics:
• The APA process is designed to meet the intent of the Forest Service Serious Accident
Investigation (SAI) process but incorporates the Doctrinal approach of principal-centered
performance rather than rule-focused compliance.
• The process forces a focus on the ‘upstream’ culture and the organization that influenced
performance. This goes beyond the proximal root cause that is typically labeled a causal
factor in other types of investigations.
• Using an APA instead of the more typical SAI process does not relieve anyone of
accountability for their actions. Had there been any evidence of a willful disregard for human
safety, the APA process would have been terminated and an Administrative and/or Law
Enforcement Investigation would have been instigated.
• The process values learning over blaming. The analysis is sufficiently complete to enable the
reader to understand what the decisions were made at the time, why they were made and how
those decisions seemed right, making perfect sense at the time. This is very powerful because
the players in this event were our most qualified and competent. If their decisions and actions
made sense to them at the time, it is very likely similar decisions and actions will make sense
again to others unless we share this experience and learn from it.
Enclosed is a question and answer document that further elaborates on this review. I encourage
every line officer and firefighter to read the report, discuss it, and learn from it. You can download
the report at: http://www.fs.fed.us/fire, under the heading: “What’s New.”

Introduction to the Cascade Complex APA

Cascade Complex APA
(8.0 MB - large file please be patient)

Forest Service Environmental Assessment of Fire Retardant and Decision Notice

FS Defines Process for Professional Liability Insurance (AGENCY ONLY)

2007 Independent Panel Large Wildfire Cost Review Recommendations
(1.6 MB - large file please be patient)