CREATING A COMMAND CULTURE BASED ON TRUST: LESSONS LEARNED AT MANN GULCH BY MICHAEL F. STALEY
We simply have not been able to figure out how to get firefighters to override their own sensibilities, contradict their survival instincts, and obey orders without question when they believe the orders are wrong. Nor would we want to.
This past summer, smoke jumpers parachuted into Mann Gulch in the mountains outside of Helena, Montana, and commenced work on 13 granite markers for 13 firefighters who perished there in 1949. Commemorating the deaths of these firefighters–even nearly 50 years after the accident–is one way we have to honor the men who served and paid the ultimate price.
As senseless as death might seem, revisiting a fatal accident site sometimes gives greater meaning to the lives lost, particularly if the lessons we learn can prevent other accidents. Seldom has this been more true than in the case of the Mann Gulch tragedy and the aftermath of reforms that resulted.
But there still remains one troubling issue that time and technology have never been able to resolve: lack of trust in leadership. Very simply, when the situation turned critical, the firefighters panicked and failed to follow orders.
It still happens.
MANN GULCH–1949 REVISITED
On August 4, 1949, a small forest wildfire broke out in the Helena National Forest. Later, fire examiners would speculate that it was probably caused by a common lightning strike. The wildfire may have had an ordinary cause, but its consequences would be anything but. The fire escalated in fury overnight. The next day was windy and hot–the thermometer read 977F, and the fire danger rating was 74 out of a possible 100. At this point, 15 trained firefighters–smoke jumpers–were dispatched into the area to bring the fire under control. Even they underestimated the fire, calling it a “10:00 fire,” meaning they felt confident that they would have it under control by 10:00. They were mistaken. Historians and poets now call the Mann Gulch fire “a race the firefighters couldn`t win.”
There was trouble from the beginning in a mind-numbing litany of mistakes, misinformation, and misconceptions that collectively led to disaster. The air above the drop site was so turbulent, the crew was forced to ascend from the usual 1,200 feet to 2,000 feet before they jumped. One of the men became so airsick that he took off his parachute, withdrew from the mission, returned to base, and resigned immediately. The radio`s parachute failed to open, and the radio shattered on impact with the ground. But, in spite of an ominous start, all the jumpers landed safely in the forest. As if this were “business as usual,” they met with Forest Service Ranger Jim Harrrison, who had been fighting the fire alone on the mountain for four hours. The crew took time to eat supper. Then they gathered supplies and discussed tactics.
Under the leadership of Foreman “Wag” Dodge and Ranger Harrison, the crew moved into position. Dodge and Harrison had scouted the area together while the crew ate and were admittedly uneasy about the thick forest that surrounded them and the potential it held for feeding an out-of-control fire. Their vague worry turned to alarm when Dodge discovered that the fire had crossed the gulch just 200 yards ahead of them and was moving toward them. He shouted for the crew to turn around and head up to the hill through tall grass toward the ridge above the fire. The fire was gaining on them with flames 30 feet high, moving more than 600 feet per minute.
Dodge quickly reassessed the urgency of their situation and ordered the crew to drop its heavy tools and run. Then he lit a fire in front of them and shouted for them to follow him into the burned area and lie down. No one in the crew obeyed Dodge`s new orders. Clearly, they thought he was insane. They all scrambled toward the ridge in an ill-fated attempt to outrun the fire. Only two made it through a crevice in the ridge. The rest of the crew–13 men–perished in the fire. It took less than 15 minutes. Dodge would rise from the safe haven to the certain knowledge that his men were dead because they had not trusted him.
The U.S. Forest Service concluded that Dodge was blameless and acknowledged that the crew could have been saved if they had followed his orders and gone with him into his escape fire. Being cleared must have been small consolation to Dodge. His men were dead.
WHAT WE LEARNED FROM MANN GULCH AND WHAT WE MIGHT NEVER LEARN
Following Mann Gulch, widespread reform resulted in policies regarding backup radios, physical conditioning that would equip firefighters to handle the rigors of wildfire fighting, more and better training regarding building escape fires, fire and weather science that provides better and more consistent information, and greatly increased safety measures.
But there have been no advances in basic human nature. We simply have not been able to figure out how to get firefighters to override their own sensibilities, contradict their survival instincts, and obey orders without question when they believe the orders are wrong.
TO OBEY OR NOT TO OBEY: THAT IS
THE QUESTION
Human nature is more powerful than all our advances in psychology, science, safety, and training put together. Widespread reforms have not been enough to keep history from repeating itself. As recently as 1994, a crew of 14 trained and experienced firefighters was not able to make the decisions necessary to outrun a wildfire and died as the South Canyon Fire swept up Storm King Mountain in Colorado. The tragedy echoed a familiar dirge from Mann Gulch.
There are many chilling similarities between the tragedies at Mann Gulch and South Canyon, but disregarding a direct command is to me one of the most compelling. In both cases, when leaders told their crews to drop their tools to run faster, the crews apparently hesitated, wasting precious time. Some even refused. When the leaders directed their crews to follow them to safer areas or deploy shelters, the crews simply did not. Researchers and scholars have tried to analyze and explain this behavior from every aspect of human nature.
Karl E. Weick of the University of Michigan has studied the Mann Gulch firefighters extensively and theorizes that many things contributed to a breakdown in command, but the most significant was the loss of structure that kept the firefighters organized.
I believe this disintegration begins at the moment a firefighter no longer trusts the leader`s judgment and decides, “This maniac is going to get me killed. I`ve got to take control myself.” He breaks–physically or emotionally–from the crew. Suddenly, alone and in panic, rational thinking gives way to more primal, instinctive reactions to the situation. The isolated firefighter who is making his own decisions may give in to the urge to “RUN” in spite of orders to the contrary.
The decisions to break from the group and disobey orders cannot be easy ones. Participants in a 1995 firefighter safety workshop stated the obvious when they said, “There is no acceptable way to disagree with orders in a command culture when individuals disagree with an action they believe is unsafe.” But they also understood the need for a degree of “democracy” when they called for effective procedures or means of communication that will allow them to have orders changed, clarified, or understood without fear of retribution. Blind obedience is being replaced by mutual trust, but it takes time to change the firefighting culture.
SEVEN WAYS TO DEVELOP TRUST
So, how do we, as leaders, create a command culture that inspires confidence, leaves room for communication, and ensures safety?
1. Let your firefighters know you. Studies confirm that firefighters find it nearly impossible to move into situations they judge to be dangerous based on the pronouncements of a stranger. The consequences of a firefighter`s pausing to weigh your credibility against every order can be fatal. This is one of the reasons we train together, so we learn to know and trust each other.
2. Admit that you don`t know everything. In a study published by Helmreich, Foushee, Benson and Russini, investigators observed that airplane captains who lead the best cockpit crews readily admitted that their ability to make decisions was not as good in emergency situations as it was at other, less stressful times. And because the captains were aware of their own shortcomings, they were good listeners, relying on input from their crews during a crisis.
In contrast, the worst leader is a “know-it-all” whose need to have the answer is so critical that he`ll go to extraordinary lengths to protect the facades he`s constructed. He`ll bend any truth and vanquish any contradiction to justify a point of view. He`s got to look good. This makes him dangerous. The investigators report that really good captains are less interested in their own reputations and more interested in the welfare of their crews. Additionally, those captains vow never to get into anything without a safe way out for everyone. It may seem contradictory to place such high trust in a man or woman who bases leadership style on admitting to not knowing everything and entering every situation with the acknowledgment that failure is a real possibility and that bailing out might be necessary, but that`s exactly the leader your crew needs.
3. Make a decision that your task is worth the risk, but be willing to rethink this in a split second. Theoretically, one of the possible contributing factors in the insubordination at Mann Gulch was the crew`s making a collective decision that it was not smart for them to put their lives in jeopardy to keep plain old trees in a remote area from burning. Frankly, who cares? It`s impossible to expect blind obedience in the face of overwhelming evidence that the order isn`t valid under the circumstances. It takes maturity and experience to be able to step back in a crisis to reassess a situation and redirect your solutions without succumbing to feelings of failure and surrender. Kenny Rogers puts it simply in his song, The Gambler. He sings “Know when to hold `em. Know when to fold `em. Know when to walk away. Know when to run.”
4. Learn how to “fail” and practice it. (I saw you flinch. Let me explain.) Author Pearl S. Buck said, “Every great mistake has a halfway moment, a split second when it can be recalled and perhaps remedied.” But you cannot identify that halfway moment if you haven`t crossed it at some point. In firefighting, we are trained to keep a situation from reaching a “halfway moment.” In doing so, however, we seldom (if ever) encounter opportunity for exercising our judgment in “off the chart” crises. It`s well known that reactions during crises are not creative; they are either instinctive or the result of overtraining–doing something over and over and over until it is second nature. In training, you need to construct and practice drills that allow your crew to experience that feeling of failure–when you all know that you`re not going to win this particular battle, but you are all going to live to tell the tale. Sometimes, losing means you`ve won. Big time.
5. Teach your crew to keep their focus on fellow firefighters. Responsibility to the group is one way to override an urge to turn and run. At Mann Gulch, for example, Wag Dodge was the leader who apparently kept his fear under control by focusing his attention on his responsibility to find solutions that would save his men. Getting a grip on your own emotions for the sake of another person is sometimes easier than trying to wrestle with your own panic. It is no accident that at Mann Gulch the two men who stuck together and ran to the ridge together survived. First, they were taking care of each other. And second, they might have recognized that contact and communication give us an opportunity to “check” our ideas and feeling with another person`s point of view. We can validate or invalidate our perceptions by comparing them with a buddy`s. You ask, “Are we OK?” And the reply might be, “Yes, we`re OK.” Or, “No, we`re in deep trouble here.” Either way, you have a second opinion, and your decision making will be much better.
6. Keep `em talking. Remember, this works best if you`ve been practicing dialogue during drills. As in all training, talking between leaders and crews can become automatic and instinctive so that you don`t have to think about it when you`re in a real situation. In a crisis, every trained firefighter has a perspective that is valuable. If you can keep respectful communication open (this includes listening), you can make yourself clearly understood and get the benefit of feedback. Let there never be retribution when a man or woman questions you or asks for an order to be clarified.
7. Trust yourself. You know what you know and, more importantly, what you don`t know. And your crew is there to support you.
THE FINAL CHALLENGE
Nothing can ensure that every order you issue will be blindly obeyed. Nor, in truth, would you want that. You`re part of a team made up of intelligent and experienced professionals who are all in this together. A few years ago, following the inquiry into the South Canyon fire, Secretary of Agriculture Dan Glickman and Secretary of the Interior Bruce Babbit issued a memo with their report to firefighters. The memo said, “Individuals must be personally committed and responsible for their own performance and accountability .U Every firefighter, every fireline supervisor, every fire manager, and every agency administrator has the responsibility to ensure compliance with established safe firefighting practices.”
The personal commitment and responsibility belong to every one of us. It`s the leader`s job to galvanize the individuals into a team with common commitment and responsibility. The glue that holds the team together is trust. n
Endnote
1. For more on Mann Gulch, see Young Men and Fire by Norman Maclean, University of Chicago Press, 1992.
