The Swiss Cheese that Allowed the Los Angeles Conflagration
Professor James T. Reason at the University of Manchester developed the Swiss Cheese Model of Accident Causation. “The Contribution of Latent Human Failures to the Breakdown of Complex Systems,” published in the 1990 Transactions of The Royal Society of London, clearly identifies these as complex human systems. The featured graphic comes from the British Medical Journal March 2000 paper, ‘Human error: models and management’.
This concept is used when discussing risk management, healthcare, and engineering. It is also a component in designing better systems under the Just Culture model. Reason points out that failure is an inevitable result of human systems—we are all fallible. Countermeasures are based on the idea that “we cannot change the human condition, but we can change the conditions under which humans work.” So, failure is seen as a system issue, not a person issue.
High-reliability organizations take this approach to failure awareness:
Analyze every event, no matter how small, to implement system-wide changes
Encourage and reward error reporting
View near-misses as opportunities for improvement rather than proof of success
Continuously learn from defects and develop failure-free processes
Two years before wildfires incineratedswaths of Los Angeles, the city’s fire chief, Kristin M. Crowley, identified “one significant area of weakness” in her department’s ability to contain wildfires. L.A. had no specialized wildland unit to respond to daily brush fires and scrape vegetation, dig ditches and do the other labor to ensure blazes did not spread or rekindle, she wrote on Jan. 5, 2023, asking for $7 million to assemble its own squad.
In a memo that has not been previously reported, she told city fire commissioners that L.A. relied almost entirely on overburdened “hand crews” from other jurisdictions to bring such muscle to its brush fire emergencies. Hand crews, the most elite of which are sometimes called “hotshots,” fight wildfires with chain saws, axes and shovels, setting containment lines and then sticking around to meticulously monitor smoldering fires, feeling by hand for heat and digging out live spots to make sure fires don’t relight.
High-reliability organizations resist oversimplification of explanations for successes and failures:
Constantly question “why” and invite diverse opinions
Avoid simplistic explanations for failures
Recognize the complexity of their work and its potential to fail in unexpected ways
Forget “wildland-urban interface”
When catastrophic fires occur, experts often blame the so-called wildland-urban interface, the vulnerable region on the perimeter of cities and suburbs where an abundance of vegetation in rugged terrain is susceptible to burning.
Yet the fire disasters that we’re seeing today are less wildland fires than urban fires, wildfire expert Jack Cohen said. Shifting this understanding could lead to more effective prevention strategies.
“The assumption is continually made that it’s the big flames” that cause widespread community destruction, he said, “and yet the wildfire actually only initiates community ignitions largely with lofted burning embers.”
The belief was that urban fires no longer exist, but they’ve come back. “It’s like watching polio return,” he said. “It’s happening repeatedly.”
While the Bel-Air fire in 1961, which destroyed 484 homes, and the Mandeville Canyon fire in 1978, which destroyed 230 homes, are often cited for the scale of their destruction, the 1991 Tunnel fire in the Oakland and Berkeley Hills marked the start of the modern era of urban fires, destroying 2,843 homes.
High-reliability organizations maintain high awareness of the state of their systems and processes:
Focus on preserving constant awareness by leaders and staff of factors affecting the mission
Proactively identify and prevent defects and harm
Use real-time data and insights to prompt action, learning, and outcomes
Officials said that the Santa Ynez Reservoir had been closed since about February for repairs to its cover, leaving a 117-million-gallon water storage complex empty in the heart of the Palisades for nearly a year. (Hamilton)
Prioritizing safety over other performance pressures
Developing the ability to assess and respond to unexpected situations quickly
Continuously learning from both successes and failures
Investing in emergency training for unlikely but possible system failures
Thirteen years ago, Los Angeles Fire Department officials were bracing for the kind of dangerous winds that could drive flames across hillsides and canyons and tear through neighborhoods from Malibu to the Pacific Palisades to the San Fernando Valley.
The National Weather Service had issued red flag warnings of doomsday gusts as fierce as 90 mph. LAFD commanders ordered up at least 40 extra fire engines for stations closest to the areas where the fire hazards were greatest, including the Palisades, The Times has learned through interviews and internal department records.
Among the additional rigs were more than 20 that were pre-deployed to those stations and 18 “ready reserve” engines that supplement the regular firefighting force in such emergencies, the records and interviews show.
“We could not take any chances on this, because the risk was too great,” said former LAFD Assistant Chief Patrick Butler, now chief of the Redondo Beach Fire Department, who led the agency’s preparations in 2011. (Tchekemedyian & Pringle) (Image is from staging for a 2010 brush fire – Mike Meadows)
High-reliability organizations value insights from those with the most pertinent knowledge, regardless of hierarchy:
Empower frontline staff to make critical decisions
Recognize that those closest to the work often have the greatest situational knowledge
Ensure leaders know who possesses specialized expertise within the organization
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