2019 WOR Day 2: Willow Rappel Fatality
June 30-July 6, 2019
This Week of Remembrance is dedicated to all those who have fallen in the line of duty and is intended to serve as an opportunity to renew our commitment to the health, wellness, and safety of wildland firefighters.
Thomas TJ Marovich Jr.
July 21, 2009, at the Willow Helibase, began like most days, fairly “standard.” Crews did what crews do in the morning and then gaggled up for briefing. TJ and his crew were slated for a proficiency rappel (proficiency rappels are required every 14 days to maintain technical competency). They prepared as they normally do, checking and re-checking equipment. Rotors are spinning; several crews had gathered to watch. Imagine the mix of excitement and pressure and maybe just a little fear.
As TJ headed to the helicopter he noticed a plastic clip, intended to prevent his harness from becoming tangled, was missing. He went to his lead and got it fixed…good to go. TJ checked his own gear…good to go. TJ’s buddy checker looked head to toe and grabbed his harness and pulled… good to go. As he climbed into the helicopter TJ’s spotter checked his gear…good to go. Four people saw exactly what they expected to see. Can you immediately spot any difference in the configurations pictured? Imagine trying to spot subtle differences in a high tempo environment.
There are actually three different gear configurations in this picture (Click to enlarge the photo).
TJ was connected to the helicopter by a rubber band. Now before you shout “there’s the problem” and “how could they miss that” remember that you have the benefit of hindsight, and no time pressure. You have the advantage of viewing a static image for comparison, and you are in the middle of a 6 Minutes for Safety session. That picture is a pretty clear cue that something is amiss and in the office today it’s easy to notice the problem. However, in the field, in the moment, life isn’t that easy. Proficiency rappels were intended to prevent just this kind of accident. And it happened anyway.
We are all a version of TJ. We are all a version of his crew that day. We do work involving risk. We practice and perform life-dependent critical tasks over and over. This work, which was once new to us, inevitably becomes normal. Think of your “standard” day. Does it start anything like this: briefing, prevention maintenance check, physical training?
How much repetition is involved? Break it down further. Is briefing always in the same format? Is the form for the engine check the same one every day? Is there a standard physical training routine?
This is all good stuff, right? Repetition builds skill, muscle memory, and automatic recall that could save your life. Right?
Is there a downside to all this repetition? Of course there is a downside; there seems to be two sides to everything. We often label the downside of repetition as “complacency.” This is a tough word. We use it as a weapon and insinuate that getting “complacent” is completely within our individual control. We promote the idea that you’re just a bad firefighter if you get complacent. Is this really accurate? Is it really possible to NOT get complacent with repetitive tasks? Is it just part of being human? Can you ever slide out of a helicopter, push a saw into a snag or get into the engine without being pretty darn sure you are good to go? Have a chat with those around you about this.
The easy wrong here is to blame TJ and his fellow rappellers for getting complacent. The harder right is remembering that each one of us is TJ – not better, not worse. You are TJ. We honor TJ through learning.
As a group, pick a repetitive task everyone performs that has become normal. Make a Pros/Cons list about repetition. Identify ways to encourage the Pros and mitigate the Cons. Repeat (with a different task).
How can YOU Honor through Learning?
The topics, review, and resources for the NWCG “Wildland Firefighter Week of Remembrance” have been contributed by the Wildland Fire Lessons Learned Center, the NWCG Leadership Committee, and many other field subject matter experts.
Incident Management Situation Report (IMSR)
10 Standard Firefighting Orders, PMS 110
18 Watch Out Situations, PMS 118
10 & 18 Poster, PMS 110-18
NWCG Incident Response Pocket Guide (IRPG), PMS 461
RT-130, Wildland Fire Safety Training Annual Refresher (WFSTAR)
Interagency Standards for Fire and Fire Aviation Operations (Red Book)
Wildland Fire Lessons Learned Center