This is a great couple of presentations that the Texas Forest Service needs to learn from. They do most of everything right on the edge and then explain later that "that is the way things are done in Texas". Not once did we see an After Action Review this year and we did see several people get "punished" for perceived transgressions related to being "overly cautious". In every case unsafe actions and the non-learning was caused by egotistical, unqualified TFS overhead.Shame on them!!
http://gacc.nifc.gov/rmcc/Risk Management 2009.pdf (and HERE in case the link is broken)
True Safety Lies in Learning
Learning is about seeing failure as part of a system.
Learning is about countermeasures that remove error-producing conditions so there won't be a next time.
Learning is about increasing the flow of safety-related information.
Learning is about…the continuous improvement that comes from firmly integrating the terrible event in what the system knows about itself.
www.fs.fed.us/fire/people/hotshots/ppts/risk-management-2007.ppt (and HERE in case the link is broken)
"A system cannot learn from failure and punish supposedly responsible individuals or groups at the same time.” ~~ Sidney Dekker