Peru is a land of contrasts. From busy, impoverished big cities to prospering (by South American standards) small towns. From the coastal desert wasteland to the Andes mountain range that tops out at over 22,000 feet.

We were successful as a 4-person team in that we summited 3 peaks. My rope partner was only successful in climbing the first peak at 18,000 + due to an illness he caught on the trip down. I got 2 peaks in with the second one being just short of 20,000 feet. After that I got a throat infection which required a trip to the local emergency room to get antibiotics.

While in our base town of Huaraz we celebrated our success and rested up for the final objective which topped out at nearly 21,000 feet. I was most of the way through my antibiotics when we left for the peak…

Summit fever (otherwise know as personal drive) is something most people discount and they figure it can be controlled. Whether on or off the job we succumb to that basic human factor probably everyday. Most of the time it does not get us into trouble, combine it with other decision making barriers (stress, distractions, etc.) and all bets are off. Establishing operational trigger points and then communicating those helps to keep us from the point of no return.

The next evening we arrived at a camp at 16,000 feet. My rope partner and I were feeling pretty rough. A plan was agreed upon to make our summit bid from that camp, knowing that we lacked the energy to carry our bivouac gear higher. We cat napped and left camp at 11pm navigating the glacier by headlamp, all four of us on one rope. This is standard procedure as you want to be safely through those highly dangerous areas before the sun loosens things up.

Sometime around 4am while resting I realized how cold it was. Most of us were wearing everything we had brought, lack of sleep, illness and high altitude were taking a toll on us. We discussed leaving behind the second rope I was carrying. I reminded the group that Dave and I would need it if we turned around before the summit. Dave and I knew if the difficulties increased we would have to turn around, the trigger point.

Around 7am at nearly 19,500 the difficulties increased. We stopped at the second belay and I realized we had met our trigger point, Dave and I uncoiled the second rope and began descending. Our Peru trip was done. Of course the good happy ending is that we made it down!

Every time I go on a adventure (fire or for fun) I realize how much control I really have over the situation. But it comes at a cost. Planning takes time and effort.

April 29, 2011 –

BOULDER — Throughout his 20 years in structural and wildland firefighting, Quinn MacLeod learned that a lot of hazards that endanger the safety of firefighters don’t come solely from the fires.

Instead, they are a result of poor communication and decision-making.

“The fire service teaches a lot about strategy and tactics but not so much about things like asking why we make particular decisions and how could we make better ones the next time,” MacLeod said. “It’s not touched on heavily until someone reaches the level of fire captain or lieutenant.”

Firefighter Quinn MacLeod’s Integrated Fire Solutions delivers training programs that focus on increasing firefighter safety. To date, he’s trained about 1,000 firefighters to reduce the number of life-threatening situations through structured decision-making and communication models. (Photo Jonathan Castner)

To fill that gap, in 2007 he opened Integrated Fire Solutions through which he delivers training programs that focus on increasing firefighter safety. The goal is to minimize human errors in emergency environments.

MacLeod’s classes focus on how to make good decisions and communicate vital information to co-firefighters when the heat is on, and the clock is ticking.

Out of the1.3 million firefighters, there are about 70,000 reported injuries every year, he explained. “And some of those are career-ending injuries.”

To date, he’s trained about 1,000 firefighters how to reduce the number of life-threatening situations through structured decision-making and communication models.

When addressing decision-making, MacLeod teaches workshop participants how to break down the process and adapt it to emergency situations.

He starts with discussing a simplified decision-making process: gather information, recognize need for decision, select course of action, make decision and evaluate results.

“At that point, the environment has changed so we’ve got new information and start the process all over again.”

In emergency situations, five barriers impact that process and can lead to human error, according to MacLeod. He categorizes them as stress, distractions, experience, physical barriers and social influences.

Preplanning to minimize the pitfalls of these barriers is the goal of his training.

MacLeod compares the stress barrier of poor planning to the experience of an unseasoned traveler.

“People who don’t travel a lot don’t necessarily know that arriving at the airport two hours early with a boarding pass in hand will reduce their stress.

“It’s those unplanned-for stressful experiences that cause people to walk off without their laptop or go to the wrong gate.”

For firefighters, something as simple as knowing how to lay out their gear in the back of a fire truck that’s racing to an emergency can reduce stress that could later impede their decision-making.

“I can’t remember anyone linking things like that together in the first ten years of my career,” MacLeod says. “Doing all these kinds of things help you operate better in an emergency situation.”

A social influence barrier that affects an emergency worker’s decision-making, is group think, according to MacLeod. “Bad group think is when the decision maker always makes decisions without getting input. What happens is that since the other people aren’t asked for input and therefore being engaged in the process, they stop taking in the environment, collecting information and passing it along.”

In training sessions, MacLeod teaches company officers to constantly seek input to keep everyone engaged and gathering information.

He teaches what he calls structured briefing — a formatted technique that could take 30 seconds to two minutes for meaningful, succinct communication.

“If people get into the habit of using the format, they’re more likely to exchange more information that increases their safety in a short amount of time.

“We didn’t look at things like that in my career and then wondered why things weren’t going so well,” he said. “We had all the information we needed but we were not properly sharing it.”

MacLeod integrated standard operating procedures from various high-risk disciplines to develop his program.

“Wildland firefighting agencies, for example, are regimented in briefing and in structure,” he said. “In structural fire disciplines, it’s not normally a formal process.”

Integrated Fire Solutions workshop rates average $1,250 a day and are taught in community colleges, through individual fire departments and at conferences. The classes bring in between $30,000 and $40,000 annually, according to MacLeod, who continues to do fire response work to road-check his material.

 By Elizabeth Gold, Boulder County Business Report

Myself and three mountain climber friends of mine are heading to the Cordillera Blanca region of Peru this coming May. In our first planning meeting our discussions bounced all over the place, from simple logistics of getting there to the actual climbs themselves. Of course the discussions always came back to the climbing routes and how high we would be climbing. All of us have summited peaks to at least 19,000 feet. The peaks we are looking at top off at around 22,000 feet. Most routes are ice and snow including the world famous snow flutes, unconsolidated steep snow mush.

Alpine climbing is kind of a silly sport. To move over terrain quick enough to avoid all the objective dangers out there you must go light. Going light means carrying as little as possible but still having enough equipment and provisions to actually pull off getting to the top. A balancing act which is ripe for human error.

I later thought about our conversations and came to the realization that I was beginning the error chain. I even opened up one thought of how each team of two climbers could “get away” with only 1 rope each. We could then combine forces at the top and use the two ropes together to rappel down. Wow sounds like a great way to shave off a few pounds of weight. Only a number of problems “could” emerge. “What if” the other climbing team does not make it to the top or they get in trouble? What if, what if, what if…

Another error chain beginning was how to “cheat” the acclimatization process. The effects of high altitude does not favor anyone. The amount of time you put into working your body to high altitude is how you keep from getting sick. Because our trip is only 2 ½ weeks we talked about the need to quickly adjust and how we could speed up the process. I have been sick up high and it is a helpless feeling.

I have been on the road a lot lately so our more recent Emails have been started to tap into each of our experiences. We are now thinking more logically about how to safely go about having a productive trip to Peru. “If we bag one summit it will be a great trip!” Experience and an open line of communication between individuals can help to lessen the amount of errors out there. Team work will help us to be resilient to the errors that we will face even in the best of conditions.

This story about personal human error can be place right into our firefighting lives. After all we as humans make all the decisions regarding error, stands to reason that we can mitigate or at least lessen the severity.

Firefighting is a dangerous job with lots of factors that are unpredictable and unforeseeable. Or are they? Whatever the investigation findings are from Kansas City there will be lessons learned and similarities drawn between that fire and many others. The trick is to take that information and internalize it. What can we do to spot those situations which lead to a disastrous outcome BEFORE they become a disaster?

The 18 “Watch Out” situations originally came from the wildland fire world. Through investigations they determined that 18 situations existed that shouted “watch out” here, you guys are heading into a bad situation.

There are several renditions of the “Structural Watch Out” situations. No matter which one you choose they serve as reminders BEFORE hand of those times when we could be putting ourselves in harms way. These must be trained on. There is no doubt we see these everyday both on incidents and in training. So bringing them into the post incident de-briefings or after action reviews (AAR) will start the process of solidifying them in the minds of our firefighters. As they become seated they will start to notice those situations as the beginning of something bad and then able to make better decisions on how to avoid the coming disaster.

Some years ago I was visiting a fire station that I had presented training to some years before. One guy said “hey Quinn we were watching the news last night about a fire and spotted a couple watch out situations they were faced with.” He told me the poster of the watch outs was hung up somewhere…

 The study of “human factors” in the fire service originated in the wildland fire community. In 1994 the USFS lost 14 of their best on a mountain side in Colorado. The investigation yielded a number of surprising and not so surprising results (unfortunately fire tragedies seem to repeat themselves). Most of the issues revolved around the decisions, human errors, and the ineffective interpersonal communication made that day.

The most popular human factors encountered in the fire service are decision making, human error, and interpersonal communication. I find it interesting that these subjects for the longest time were presented only to our upper management (Division, Assistant, and Department Chiefs) as if they were the only ones faced with needing this knowledge. Eventually this information was shared with the middle management (Company Officers and Battalion Chiefs) as they really do live this knowledge in our most hazardous environments.

In more recent times human factor knowledge can be found most everywhere for all fire service personnel. Yes even the rookie firefighter makes decisions and must be able to communicate their thoughts effectively. I believe there is a huge benefit for all personnel to understand that human actions dictate most everything which happens on the emergency scene. I say this because there is still a disproportioned amount of “talk” regarding how a tool or tactic was utilized instead of why it was used in that manner.

A reason to care about the effect of human factors in the fire service is the benefit of digging down a layer or two and exposing the “why” behind what we do. By bringing to light why a tool or tactic was used in a particular fashion allows us to discuss this in a professional manner and flush out ways of improving.

Hey now were onto something. I have been involved in numerous discussions after incidents or trainings were we figured out ways of improving our efforts. What we may have not exposed was how to keep it from going wrong in the first place or at least how to minimize the bad effect.

If understanding and utilizing human factors to the fullest extent was easy the fire service would have done it 200 years ago. Just think of the reduction in injuries and fatalities. But it’s not easy, were human after all.

The article said that researchers conducted experiments utilizing structure and vehicle fires, they then measured the amount and specific characteristics of breathable particulates released during combustion. They do say it was the first experiment of its type.

When I started in the fire service in the mid 80s, it was known that the chemical gases are still lingering inside the structure during overhaul. So why are many departments still not wearing SCBA throughout the overhaul stage? The article mentions the weight of the SCBA as one reason which would increase fatigue especially if the person was in poor physical fitness. But could it be something else? Perhaps there is a thinking that the “fight” is over and now it’s just the necessary evil before heading back to the station.

When looking at the overarching picture there are many barriers to decision making present when entering the overhaul stage of fire operations. Stress, fatigue and inhalation of the products of combustion are at work against our better judgments.

A young firefighter who was standing near a tree cutting operation was struck by a falling piece of debris. His leg suffered severe blunt trauma which was compounded by an arterial bleed. Due to a series of problems ranging from remoteness of the accident site to numerous miscommunications, his transport from the scene took several hours. He was pronounced dead at the hospital later that afternoon.

On and off the fireground we glide through the day giving and receiving indirect communication. All of a sudden we are in a situation that requires very precise, effective, direct communication. Afterward we wonder why it did not happen. Extended operations are difficult to keep up the intense direct communication. As humans we are susceptible to becoming fatigued and lose focus, amongst many other natural human tendencies.

Being aware of the differences between indirect and direct communication is a good start. It is something that the fire service does not have a list of training classes to cover, which is unfortunate since we communicate all the time…

The report is a very big file but the narrative is worth a read. Notice the timeline with regard to the “report of the accident.”