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INVESTIGATING
INVESTIGATIONS
to advance the
State-of-the-Art of
investigations, through
investigation process
research.
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Launched Aug 26 1996.
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from the perspective of an investigator.
by Ludwig Benner, Jr.
YOUNG MEN AND FIRE, by Norman Maclean, University of Chicago Press, Chicago, IL,
(1992) ISBN: 0226500616
301 pages
Young Men and Fire tells the story of a 1949 Rocky Mountain forest fire that that claimed the lives of 13 young smoke jumpers, at Mann Gulch, Montana. The firefighters perished in a "blowup"--an explosive, 2,000-degree firestorm 300 feet deep and 200 feet tall - from which they were unable to escape.
This book is written by someone who has faced similar dangers. It describes in detail how 11 firefighters met their deaths in a mountain fire started by lightening in a remote gulch in the Rocky Mountains. What makes it especially interesting is that the author spent 14 years trying to reconstruct what happened, because of uncertainties not resolved by the original fire investigation. As investigators read this book, they will recognize how investigation inadequacies impeded the learning of lessons from the experience. Many changes were made in response to readily apparent shortcomings in then existing concepts and practices disclosed by the investigation. However, critical questions affecting future polices and practices remained unresolved until the author took the time to resolve them. It wasn’t easy. The book discloses some of the consequences of investigations that do not establish with reasonable confidence what happened and why it happened. Interestingly, like Vaughan’s inquiry into the Challenger Launch Decision (and the investigation problems it exposed), the author returned to original data sources to resolve the controversy.
The author’s description of his efforts to reconstruct behaviors and actions during the fire is moving, in the context of his age and obstacles he faced.
An interesting story within the story is the description of how mishap experience can lead to discovery of unknown unknowns for which extensive research was needed, and the description of how pioneering work can be achieved by one individual who simply took the initiative to answer some basic questions about forest fires scientifically.
For me personally, the author’s reconstruction of the actions and decisions of the firefighters during the fire provides thought provoking insights into individual’s behavior in adaptive learning situations when trained individuals confront something which their training does not address.
I commend the book to investigators of any kind of mishap.
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