Organizational Learning from Prescribed Fire Escapes: a Review of Developments Over the Last 10 Years in the USA and Australia

Abstract

Purpose of Review: Prescribed fire escapes continue to challenge most fire and land management agencies and many communities. This article considers the issue from knowledge management (KM) and organizational learning (OL) perspectives. We review organizational initiatives and the literature that have developed over the last 10 years to support learning from escaped prescribed fires, then use this to evaluate current learning practices and identify potential next frontiers for improving performance. Due to the difficulty obtaining statistics for non-federal entities, this review focuses primarily on developments in the US Department of Agriculture, Forest Service, but also captures reviews from the US Department of Interior, and the State of Victoria, Australia.
Recent Findings: The recurring issue of prescribed fire escapes may in part be explained by the increasing challenges and expectations fire and land management agencies and prescribed fire managers face. Agencies are being asked to burn more area and suitably contain prescribed fires with fewer resources. In many jurisdictions, this challenge is heightened by increasingly tough climate conditions, shifting demographics internal and external to their agencies, changing patterns of land use, and requirements to meet increasing fuel reduction targets. A range of interventions has been developed and implemented by state and federal land and fire management agencies to support improved performance through KM and OL. However, prescribed fires continue to escape, often for the same reasons they always have, leading us to ask: is there a next frontier or level for improving performance though learning?
Summary: This paper reviews recent developments in KM and OL to develop a model of organizational learning for prescribed fire. We then use this lens to review learning from prescribed burn escapes in Australia and the USA, highlighting the opportunities and challenges that agencies continue to face. Four areas of concentration to further strengthen OL are proposed, namely (i) strengthening the organizational learning culture, (ii) greater use of communities of practice to enhance lesson sharing, (iii) addressing the slow build time for prescribed burning expertise to replace pending retirements, and (iv) improving non-technical skills and human factors training.

Full text

FIRE SCIENCE AND MANAGEMENT (ME ALEXANDER, SECTION EDITOR)
Organizational Learning from Prescribed Fire Escapes: a Review
of Developments Over the Last 10 Years in the USA and Australia
A. E. Black
1
&P. Hayes
2
&R. Strickland
3
#This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply 2020
Abstract
Purpose of Review Prescribed fire escapes continue to challenge most fire and land management agencies and many communities.
This article considers the issue from knowledge management (KM) and organizational learning (OL) perspectives. We review
organizational initiatives and the literature that have developed over the last 10 years to support learning from escaped prescribed
fires, then use this to evaluate current learning practices and identify potential next frontiers for improving performance. Due to the
difficulty obtaining statistics for non-federal entities, this review focuses primarily on developments in the US Department of
Agriculture, Forest Service, but also captures reviews from the US Department of Interior, and the State of Victoria, Australia.
Recent Findings The recurring issue of prescribed fire escapes may in part be explained by the increasing challenges and expectations
fire and land management agencies and prescribed fire managers face. Agencies are being asked to burn more area and suitably contain
prescribed fires with fewer resources. In many jurisdictions, this challenge is heightened by increasingly tough climate conditions,
shifting demographics internal and external to their agencies, changing patterns of land use, and requirements to meet increasing fuel
reduction targets. A range of interventions has been developed and implemented by state and federal land and fire management
agencies to support improved performance through KM and OL. However, prescribed fires continue to escape, often for the same
reasons they always have, leading us to ask: is there a next frontier or level for improving performance though learning?
Summary This paper reviews recent developments in KM and OL to develop a model of organizational learning for prescribed fire. We
then use this lens to review learning from prescribed burn escapes in Australia and the USA, highlighting the opportunities and
challenges that agencies continue to face. Four areas of concentration to further strengthen OL are proposed, namely (i) strengthening
the organizational learning culture, (ii) greater use of communities of practice to enhance lesson sharing, (iii) addressing the slow build
time for prescribed burning expertise to replace pending retirements, and (iv) improving non-technical skills and human factors training.
Keywords Prescribed fire .Organizational learning .Knowledge management .Escaped fire
Introduction
Aside from climate, fire is arguably the most powerful macro-
scale force influencing historical evolution of much of the
Earth’s terrestrial flora and fauna [1–4]. Naturally ignited fire
(wildfire) continues to play a critically important regenerative
role in many ecosystems (e.g., [4,5]). Historically, socially
oriented human-ignitions have created and maintained cultur-
ally important and ecologically rich ecosystems resulting in
substantial changes to the geographic range and composition
of many vegetation types [3,6–8].
Intentional human application of fire continues to be an
important management tool. Every year, millions of hectares
of grass, scrub, and forest undergo prescribed burning around
the globe. Prescribed fire is used to maintain or improve bio-
diversity; support natural ecosystems; and restore, maintain,
This article is part of the Topical Collection on Fire Science and
Management
Electronic supplementary material The online version of this article
(https://doi.org/10.1007/s40725-019-00108-0) contains supplementary
material, which is available to authorized users.
*A. E. Black
anne.e.black@usda.gov
P. H a y e s
peter.hayes2@rmit.edu.au
R. Strickland
stricklandwildfire@gmail.com
1
USDA Forest Service, Rocky Mountain Research Station,
Missoula, MT 59801, USA
2
RMIT University, Melbourne, Australia
3
Country Fire Authority, Melbourne, Victoria, Australia
https://doi.org/10.1007/s40725-019-00108-0
Current Forestry Reports (2020) 6:41–59
Published online: 12 March 2020

and conserve fire-adapted landscapes (e.g., [9]). Prescribed
fire is also increasingly used to reduce wildland fire (bush-
fire
1
) threat by consuming fuel, thus reducing the rate of
spread and intensity of subsequent fires, and thereby generally
reducing suppression difficulty [11–13].
Prescribed fire is an intensively planned affair. Here, we
use the term to mean intentional ignitions planned and imple-
mented by professionals as part of their land management
agency’s operations to meet management objectives, and in
contrast to accidental or arson starts. Although specifics vary
by country and organization, prescribed fire entails significant
pre-work (e.g., consultations to articulate burn objectives,
fieldwork to identify fuel types and conditions, appropriate
weather and burn conditions, burn boundaries, topography,
infrastructure, and associated personnel and resources needed
to complete a successful burn) [see 14,15 for more]. This is
compiled into a “burn plan”that describes all facets of imple-
mentation: ignition, holding, and contingency plans. A burn
plan must be approved by appropriate authorities. Many pre-
scribed fires are years in the planning; implementation must
then await appropriate environmental conditions. Similarly,
although criteria vary for when a prescribed fire is classified
as “escape,”in general, an escape occurs when the onsite
resources (including contingency resources called for in a
burn plan) can no longer contain the fire as planned.
2
Recent devastating losses from wildfire—of life, private
and corporate property, and critical infrastructure–events
around the world: in the USA (California) in 2017–2018; in
Canada in 2016 (Alberta) and 2017–2018 (British Columbia);
in Croatia, Portugal and Spain in 2017; and in Australia in
2009, 2019/2020—bring new urgency to discussions regard-
ing the use of prescribed fire to mitigate or avoid destructive
unplanned ignitions. Prescribed fire has much to offer: it ef-
fectively reduces wildland fuels, typically at a lower cost than
suppression and mechanical fuels reduction operations and is
a natural process that can enhance and improve ecosystem
resilience [9].
Yet, even as the need increases, so do the challenges.
Challenges arise at both planning and implementation
phases:
&Planning phase:
–Ongoing evolution of agriculture and tourism create a
more complex mosaic of land use and ownership and
the interplay between social, economic, environmental,
and cultural aspects make it increasingly difficult to
achieve prescribed fires in some regions [16•,17,18]
–Demographic changes reduce capacity and knowledge
(e.g., aging population, new residents’lacking fire expe-
rience, depopulation of rural areas and resultant loss of
cultural practices) [4,16•,19–21,22•]
–Concerns over air quality and potential escapes can jeop-
ardize community support and agency license [5,20,22•,
23–25]
&Implementation phase:
–Fuel build-up from decades of attempted fire exclusion
and fire suppression increases potential fire behavior,
making control of wildfires increasingly difficult [4,
16•,26,27]
–Climate change results in more frequent incidents of ex-
treme fire behavior, increases length and severity of
drought which result in more difficulty complying with
burn prescriptions [28–31]
–Correctly perceiving, understanding, managing, and
communicating risk and uncertainty is an ongoing human
factors challenge [4,16•,20,21,32–34]
–Challenges of ensuring good practice among non-
professionals (i.e., citizens) burning private property
[16•]
–Changing structure of agencies, including outsourcing
and an increasingly aging (and retiring) workforce exac-
erbates gaps in burn skills and experience [29,35]
These challenges make the path to success tortuous. Once
planning is complete, it can take years for the appropriate
conditions—environmental and organizational—to occur.
Once ignited, the uncertainties in the dynamic interactions
among weather, topography, fuels, fire, and human behavior
make prescribed burning a complex and inherently risky en-
deavor [36]. Successful prescribed fire operations require
competent individuals to function in effective teams, which
themselves rest within multi-team organizations that operate
at various scales.
Although escapes are uncommon (less than ~ 1% of
all prescribed fires) and those resulting in significant
property damage and injury even more rare, they can
have enormous impact—on individuals, on affected
communities, on the wildland fire community and oper-
ations, and on public policy and perception. For exam-
ple, the 2000 Upper Frijoles prescribed fire escape
(which became more widely known as the Cerro
Grande wildfire) in New Mexico destroyed 235 homes
[37]. The Margaret River prescribed fire escape in
Western Australia destroyed 41 houses and heavily
disrupted tourism central to the region’s economy [20]
(see Sidebar). Escapes almost always result in the
1
The term bushfire is a collective term used by Australians to describe fire in
the rural countryside and includes grass, scrub, and forest [10]. A bushfire is
known as wildland fire in North America.
2
In the USA, when project resources are not able, or are projected to not be
able, to contain any fire outside of the approved burn unit within 24 h, it must
be declared an escape. Sometimes an escape is also called when additional
funds are needed to pay for contingency resources.
Curr Forestry Rep (2020) 6:41–59
42

cessation of other local burn operations and sometimes
nationally. Such response, although understandable,
limits the ability of a prescribed fire program to meet
its objectives.
In light of these challenges, it is incumbent on organi-
zations to glean as much learning as possible from each
burn and successfully incorporate those insights and les-
sons into future program operations. To assist in this, we
critically review how organizations are learning, specifi-
callyhowtheyareseekingtoreducefutureprescribedfire
escapes by incorporating lessons learned from previous
escapes, and identify potential next steps towards improv-
ing learning. Although this is not the first such effort to
summarize learning from events (see examples: Maupin
[38,39] and Jin and McRae [40] for meta-reviews
targeting fire managers, Wier et al. [41] for lessons and
providing succinct guidance, Moriarty et al. [42]foran
academic treatment of insights gained in one fuel type and
see Black et al. [43] for structured review of organization-
al learning).
This paper includes an academic review of materials
published over the past decade by fire and land man-
agement agencies intended to help their program person-
nel learn in the aftermath of prescribed fire escapes.
Most fire management organizations have come to real-
ize over the past decade that unintended outcomes, al-
though rare, are extremely difficult to avoid. Thus, in
addition to doing their best to avoid them they have
adopted techniques to learn from their performance
(both positive and negative).
Learning itself is complex. Researchers emphasize
emergent and fluid characteristics [44]aswellastheso-
cial complexity of organizations themselves [45].
Learning from prescribed fire escapes involves processes
to build individual competence and team skills (explicit
and tacit; procedural and experiential), prior to, during,
and post implementation. Ideally, organizational learning
processes capture, retain, and transfer new understandings
across individuals, jurisdictions, and time. Ghili et al. [45]
argue that organizational learning acts as a mediator be-
tween organizational innovation and knowledge manage-
ment, between the during-action dance of individual and
team performance (innovation) and the post-action struc-
tured, bureaucratic process of knowledge capture, synthe-
sis, distribution, and integration. Throughout, the social
and structural complexity of organizations themselves cre-
ate challenges for how to best support and enable organi-
zational learning.
Here, we assess experiences and insights gained and
documented over the past decade from escaped pre-
scribed fire reviews through the lens of conceptual de-
velopments in the fields of organizational learning,
knowledge management, and organizational
development. We focus primarily on the USA and
Australia due to availability of data.
Methods
We conducted literature searches of both peer-review and
“gray”literature in order to contextualize the practice of pre-
scribed fire and its role and challenges as a land management
tool and to identify discussions and reviews of escaped pre-
scribed fires. We focused on documents published and pub-
licly available between 2012 and 2018. Most published re-
views fall into the “gray”literature category as they are rarely
peer-reviewed from an academic or professional perspective.
Reviews are commissioned by governmental entities written
by teams selected for their peer- and managerial-fire expertise
and usually follow the escape of government agency pre-
scribed fires resulting in major losses. In the USA, federal land
management agencies with fire responsibilities include the
Forest Service of the Department of Agriculture and the
National Park Service, Bureau of Land Management,
Bureau of Indian Affairs and Fish and Wildlife Service of
the Department of Interior. Individual states and local govern-
ments have fire responsibilities for private and state-owned
lands within their jurisdictions. However, due to the consider-
able difficulty collecting comparable data from multiple agen-
cies (five US federal agencies and 50 states; six Australian
states each with two land management agencies), this review
includes data largely from the Victorian Department of Land
Water and Planning (DELWP
3
) which has had the most recent
published review of its prescribed fire practices and the US
Forest Service. The lack of literature covering escapes from
prescribed fires on private lands in both the USA and
Australia precluded review of this sector.
We analyzed published reviews (management-oriented
non-academic literature) to detect patterns in the prescribed
fire escapes themselves, the presumption being that patterns
are indicative of tractable issues organizations can address, as
opposed to random events that are not tractable. One indica-
tion of learning might be that there are new patterns in the
causes of prescribed fire escapes.
We simultaneously conducted a search of the academic
peer-reviewed literature. We summarize recent theories of or-
ganizational learning and use this to identify a practical ana-
lytic framework. Our search for recent organizational learning
papers quickly led us into the related realm of knowledge
management, where recent focus is mainly on codification
of explicit insights into durable organizational processes. A
3
In Victoria, the Forests Act of 1958 designates that DELWP is “responsible
for the immediate prevention and suppression of fire and for planned preven-
tion of fires in state forests, nationalparks and on public protected land”[32,p.
4]. The Country Fire Authority (CFA) is responsible for suppression and
prevention of fire on private land in the more rural areas of the state.
Curr Forestry Rep (2020) 6:41–59 43

complex endeavor such as prescribed fire, however, requires
refined judgment of nuanced variables; thus, the transfer of
experience and tacit knowledge is vital to success. We needed
a multi-faceted framework that allowed us to consider learn-
ing from a variety of perspectives: scales of learning (individ-
ual, team, organization, inter-organization), time frames of
learning (in-the-moment, reflective), types of knowledge (ex-
plicit, tacit, procedural, experiential), and processes of organi-
zational learning (creating, retaining, transferring). Thus, we
venture into aspects of organizational development and reach
a bit further back in organizational learning theory to develop
a sufficiently comprehensive framework. We then consider
recent advancements in organizational learning processes for
prescribed fire events in the USA and Australia through this
emergent lens. We end with some thoughts on advances and
current knowledge gaps that may be more productively ex-
plored in order to continue to improve prescribed fire opera-
tions and organizational learning.
Results and Discussion
Organizational Learning—Model Review
and Framework Development
At least one recent review of the knowledge management and
organizational learning literature suggests that knowledge
management has absorbed organizational learning [cf. 46].
We disagree, at least as it relates to the practice of organiza-
tional learning. Current peer-review literature focuses on the
structuring of knowledge maintenance rather than the process
of learning. We seek to recover the learning phase and place it
back in its proper and useful relationship. For instance, with
the advent of big data, recent scholarship has virtually explod-
ed with papers covering mechanisms for capturing, analyzing,
and serving back know-how (e.g., building call center data-
bases to assist with “known”issues). Although this is a core
function of a learning organization, alone it is insufficient to
achieve learning. Current literature is missing the myriad of
ways in which organizations are expanding their practices of
learning, as we explore in the context of prescribed fire es-
capes. It is also silent as to how an organization, particularly a
field-oriented one, successfully moves lessons from databases
to humans and instills these in current and ongoing training
and operations.
Generically speaking, an organization’s performance is
comprised of both the application of prior experience (i.e.,
knowledge) and the process of acquiring and applying new
knowledge (i.e., learning). Argote [47] defines three facets of
knowledge: declarative (explicit understanding and facts), tac-
it (difficult to articulate and often experiential), and procedural
(routines). Knowledge can be embedded in multiple locations
including people (competent individuals, teams), routines
(organizational processes), and knowing who knows what
(transactive memory). Organizational learning is defined as a
change in the organization’s knowledge in response to expe-
rience [47,48]. Change can be observed in organizational
routines, cognition, and/or behavior, incorporating explicit
and/or tacit elements [49•], at individual, team, organizational,
and inter-organizational scales [50]. In general, organizational
learning is considered an intentional activity [51]; however,
cultural change is often accidental or indirect. Lessons may be
positive (i.e., advances the organization’s culture and practice)
or negative (driving individuals and organizations into defen-
sive modes) [52], based on the actual story (first-story) or on
the meaning others assign to the narrative (second-story) [53].
Occasionally, there may be the need to remove (or forget) poor
practices [54].
Argote and Miron-Spektor [49•] theorize a cyclical process
in which experience gained through performing a task is trans-
lated into knowledge that shapes the organization’s context
and influences future experiences. Drawing from Glynn
et al. [55], the authors highlight how organizational learning’s
interrelated sub-processes of creating, retaining, and transfer-
ring knowledge occurs in a context that includes the organi-
zation and the environment in which the organization is situ-
ated (Fig. 1).
In this view, learning is largely retrospective. Christianson
et al. [56•], however, define organizational learning as “revi-
sion of response repertoires in ways that improve organiza-
tional performance”. This usefully redirects our attention
away from a sole focus on post-event changes in behavior
and routines, towards examining the ways in which various
actors, skills, routines, beliefs engage with an unfolding event;
that is, learning through in addition to learning from.Intheir
Fig. 1 A theoretical framework for analyzing organizational learning
[Source: 47]
Curr Forestry Rep (2020) 6:41–59
44

words: learning through is “learning focused on discovering
and strengthening a set of organizational routines that facili-
tate the resumption of activity as the interruption winds
down”.Incontrast,learning from is “learning as a separate
event”[56•, p.850]. It recognizes that in the lead up to an
unexpected event, people are acting and behaving as they
normally do—that is, using “pre-existing repertoires.”This
allows the re-framing of a prescribed fire escape from a rare
event that is difficult to learn from due to its uniqueness to a
series of typical behaviors “less unique and less idiosyncratic
than is the rare event itself”[56•, p.850]. As a consequence,
the frequency and landscape of learning—who, what, where,
when, and how—is dramatically expanded. We can now con-
sider events as: (1) “audits of existing response repertoire,”(2)
“disruptions that provide opportunities to reorganize routines
particularly with respect to interpreting, relating, and
restructuring,”and (3) events that “redirect organizational
identity”[56•, p.847]. Each of these enriches our learning.
Edmondson and Harvey’s[57] review also draws attention to
these distinct frames. Their streams of organizational learning—
production and innovation—also focuses on the learning through
rather than learning from, yet further distinguishes these as doing
(in-the-moment) and reflecting (backcasting). This is a subtle
refinement of Argyris and Schon’s[58] single and double-loop
learning (refining existing routines as production, and fundamen-
tally altering routines as innovation) by distinguishing, and thus
highlighting the value of, in-the-moment learning from reflective
learning. Owen’s[59•] survey of how emergency management
organizations utilize research is an example of the production
stream. Owen observes that leading agencies (mature utilization)
establish governance processes to ensure utilization of new
knowledge, embed insights into job roles, actively test outputs,
and support communities of practice. Improving the production
stream involves understanding and working to bureaucratize and
structure learning into new skills, processes, structures, and to
some extent, culture. When project implementation does not go
according to plan, generally, what is required is in-the-moment
innovation—using what is known in new ways or creating an
entirely new way. Improving performance via this stream sug-
gests a focus on new paradigms of work culture, such as facili-
tated teaming [60] and encouraging high reliability behaviors
[61,62] to promote role clarity, sense of belonging, and psycho-
logical safety, which in turn nurture dynamic learning behaviors
such as seeking feedback and ability to quickly experiment, as-
sess response, and keep moving. Edmondson’swork[63•]con-
tinues to highlight the critical importance of a psychologically
safe climate for successful in-the-moment performance.
What emerges for us from the preceding review of the
literature is a comprehensive learning framework such as
displayed in Fig. 2.
According to this framework, after preparing for an opera-
tion using existing explicit procedures, knowledge, and rou-
tines, individuals and teams engage and learn in-the-moment
during operations drawing on the team’s culture, collective
skills, tacit knowledge, intuition, and transactive memory.
Afterwards, they engage in explicit backcasting, in structured
and unstructured ways to gain insight into the events’evolu-
tion and result. Insights are captured, ideally in a form that
facilitates the documentation and/or cultural retention, so that
these are transferred between people, units, across time and
space to influence future preparations and operations.
Organizations and communities of practice further reflect on
these events (sometimes significant individual events, some-
times patterns emerging across multiple events), identify new
and reinforced preparatory processes (policy, training, plan-
ning routines), and potentially new implementation reper-
toires. An important step is the tracking and analysis of both
tacit and explicit forms of learning and knowledge retention so
as to improve impact on future efforts. Activities are influ-
enced by other features of the latent organizational context
(e.g., human resource practices, culture, mission) and the
broader environmental context (e.g., ongoing changes in
extra-organizational policy, demographics, land use, climate).
Status and Current Focus in Prescribed Fire
Management
In this section, we briefly outline prescribed burning activities
and information related to escapes on National Forests in the
USA and the State of Victoria, Australia. Table 1shows the
number of prescribed fires and escapes for the US Forest
Service between 1996 and 2014 and DELWP operations be-
tween July 1, 2005 and June 30, 2015.
We note that the trend suggested by the data given in
Tab le 1appears positive. However, there is concern that the
highly skilled prescribed fire practitioners who have contrib-
uted to these trends are retiring more quickly than they are
being replaced. Moreover, the increasingly demanding condi-
tions for conducting these operations means that organizations
and fire practitioners will be required to learn more quickly.
Finally, these statistics are lag indicators telling us what has
happened rather than providing present or forward looking
indicators of capability and organizational culture.
US Federal Lands
National statistics tracking prescribed burning by the largest
federal forest land management agency in the US report a
consistent trend of less than 2% occurrence of prescribed fire
escapes (Table 1). We were unable to find any comparable
reports for other federal agencies, state, or private land man-
agement organizations.
For this paper, we read all publicly accessible reviews
of prescribed fire escapes (n= 34) undertaken in the US
since 2012 (Table 2) as published on the interagency
Wildland Fire Lessons Learned Center’s(WFLLC)
Curr Forestry Rep (2020) 6:41–59 45

website (www.wildfirelessons.net/home). From these
reviews, we found no obvious pattern in the types of
prescribed fire escapes. There were escapes in all
configuration of fuels (e.g., piles vs. broadcast), at all
times of a prescribed fire operation (i.e., test fire,
ignition, holding, patrol, and mop up), among all types
of vegetation/fuel complexes (e.g., grass, shrub, forest),
during the first fuels reduction entry or after multiple
entries, and/or type of burn desired (e.g., underburn, stand
replacement). Similarly, the escapes reviewed in these
documents are the consequence of surprises in fuel recep-
tivity, the capricious nature of winds, and erratic though
expected fire behavior. Most discuss lessons in one form
or another. Lessons learned covered a wide spectrum,
from local, operational insights (such as when to move
equipment), to broader recognition of the need to build
Do
Reflect
Prepare
Journaling
Data Collecon
Analysis
Integraon into Policy,
Rounes, Skills
Behaviors, Identy
Sense-making
Forecasng
Analycal
Explicit
Back-casng
Analycal
Explicit
In-the-moment
Intuive, Interacve
Tacit
Retain
Transfer
Capture
Storytelling
Storytelling
Training
Pracce
Self-study
Storytelling
Latent organizaonal context
Environmental context evolving over me
Fig. 2 Proposed framework to analyze organizational learning for prescribed fire identifying major phases; activities; temporal, cognitive and knowledge
frames; and contextual exchange. Adapted from [43]
Table 1 Recent prescribed fire statistics for the US Forest Service and Victoria, Australia
Agency US Forest Service [64] DELWP Victoria [32]
Period 1996–2001 2003–2007 2007–2014 2005/06–2009/10
a
2010/11–2014/15
a
Number of prescribed fires 24,133 19,468 33,677 3056 3371
Annual average 4022 3980 4811
Acres treated 6,406,217 7,079,427 9,812,690
Annual average 1,067,703 1,415,885 1,401,813
Escapes 235 50 45 51 20
Annual average 39 10 6
Reliability rate 99.03% 99.75% 99.87% 98.33% 99.40%
a
The fire season in Australia is typically reported July 1st to June 30th. Hence reporting is in the format 2005/2006 etc.
Curr Forestry Rep (2020) 6:41–59
46

relationships (such as with the weather service), to
staffing (consistency, but also a few regarding expertise).
Among the host of human factors described, lessons in 18
of the 34 reports noted some aspect of communications
(adequacy, clarity, process, skill, culture to support speak-
ing up, technical issues) urged wariness of expectations
(for instance, of under what conditions boundaries will
hold). Fourteen of the reports noted the need for addition-
al resiliency to adapt to changing conditions. Twenty of
the reports noted the need for attention to some aspect of
contingency resources.
Victoria, Australia
Similar to other southern Australian jurisdictions, Victoria has
a long history of conducting prescribed burning operations
and thus a commensurate history of escaped prescribed fires.
Unfortunately, Victorian agencies have published very limited
statistics on their prescribed fire escapes, thus limiting our
ability to track improvement efforts. Most of the publicly
available information on prescribed fire escapes is from the
DELWP and its predecessors. However, escaped planned fires
on private land is a significant issue, albeit more difficult to
Table 2 A sample of prescribed fire escape reviews in the USA from 2012 to 2018
Year Review name State Agency* Escape phase Fuel type Burn type Review type** Lessons
2012 Apalachicola Unit 208 FL USFS Patrol Underburn Broadcast Unstated Y
Box Creek UT USFS Firing Stand-replace Broadcast FLA Y
Compartment 7 NC USFS Mop up Understory Broadcast Unstated Y
Cottonwood CA USFS Firing Brush Broadcast FLA Y
Forest Health SD USFS Holding Slash Piles Unstated Y
Lower North Fork CO State Mop up, patrol Restoration Broadcast Key factors Y
North Schell NV USFS Firing Stand-replace Broadcast FLA Y
2013 Belle Fourche SD NPS Firing 2nd entry Broadcast Unstated Y
Pasture 3B SD USFS Patrol Grass Broadcast Unstated Y
Stump Springs UT USFS Firing Understory Broadcast Unstated Y
2014 Pole Creek WY USFS Firing Stand-replace Broadcast Unstated Y
Tract 17 CA NWR Firing Grass Broadcast Unstated sort of
2015 Arapaho CO NWR Firing Grass Broadcast Review Y
Bone Point OR USFS Fire behavior Understory Broadcast Unstated sort of
Cold Brook SD NPS Holding Grass Broadcast Unstated Y
Flat Ridge UT USFS Firing Sage/timber Broadcast Unstated Y
2016 East Maury OR USFS Firing, holding Understory Broadcast Unstated Y
Foss Lake MN USFS Firing Masticated fuels Broadcast Unstated Y
Little Valley NV State Mop up Fuel reduction Broadcast Unstated No
Zimmer Ridge SD USFS Patrol Slash Piles AAR Y
2017 AQ WA USFS Firing, holding Timber Broadcast Unstated No
Johnson Ridge UT USFS Firing Heavy brush Broadcast Unstated Y
Onion Creek House TX City Firing Grass/brush Broadcast Unstated Y
Pole Creek WY USFS Patrol/monitor Stand-replace Broadcast FLA Y
Ponderosa Pile CA USFS Firing Heavy Pile Review Y
Wewoka OK BIA Patrol First entry Broadcast RLS Y
2018 Compartment 4 FL NWR Aerial ignition in wrong area Maintenance bun Broadcast Review No
Gallinas NM USFS Firing/patrol Fuels Piles/broadcast FLA Y
Lodgepole Springs ID USFS Patrol Broadcast FLA Y
Pine Grove SD USFS Patrol Pile FLA sort of
Redondo NM USFS Review separate from FLA Unstated
Santa Cruz Island CA NPS Patrol Piles FLA Y
Sims/Grape CA USFS Post-fire Piles FLA Y
West 83 NE *USFS Mop up Grass Broadcast Unstated Y
*USFS US Department of Agriculture, Forest Service, NPS US Department of Interior, National Park Service, NWR US Department of Interior, National
Wildlife Refuge, BIA US Department of Interior, Bureau of Indian Affairs, **FLA Facilitated Learning Analysis, AAR after-action review, RLS Rapid
Lesson Sharing
Curr Forestry Rep (2020) 6:41–59 47

obtain data on. For example, during a period of adverse fire
conditions on October 6, 2015, more than 40 calls were made
to Victorian authorities regarding re-ignitions and escapes
from planned burns on private property [32]. By way of com-
parison, approximately 2% of planned ignitions on public
lands in Western Australia (WA) have escaped [36].
However, it is important to note that the annual planned burn-
ing programs in WA typically involve considerably larger
areas [65].
Organizational Learning in Prescribed Fire
In this section, we outline significant events or changes over
the past decade in the prescribed fire learning environment in
each country. In the USA, this is focused on new institutional
learning processes for any fire-related accident—wild or
prescribed—and insights gained from a 2012 review of learn-
ing specifically from reviews of prescribed fire escapes. In
Australia, especially Victoria and WA, several fire events
and their subsequent reviews have altered prescribed burning
policies and practices.
We then use the organizational learning framework intro-
duced earlier (Fig. 2) as a lens through which to assess a
selection of current learning activities, focusing on recently
published reviews of prescribed fire escapes. We distinguish
the first three steps (prepare, do, reflect), then consider a sec-
ond set (capture, retain, transfer) together in order to better
discuss how tacit and explicit knowledge is treated. In the
USA, these reviews—covering the full gamut of escape
consequences—are commissioned or requested by local au-
thorities and undertaken by a mix of internal experts and
peers. Reviews of the more minor escapes in Victoria were
also carried out by a mix of senior officers, fire managers, and/
or peers, but the results were not released. Without knowing
precisely why not, and without an authoritative explanation,
further comment would at this point be speculative. Reviews
of escapes with more serious consequences are generally con-
ducted by a third party.
The USA
Since 2000, US wildland fire organizations, and in particular
the Forest Service, have worked to change how they respond
when operations go wrong, devoting considerable effort to
cultivating a learning as opposed to a blaming orientation
towards human error. The primary goal was to develop a
completely different process for learning from events, revise
policy, and develop training, educational materials, and a cad-
re of people skilled in the capture of information that helps
both the prescribed burn team members involved and the or-
ganization to learn from the prescribed fire escapes. The US
Forest Service formally adopted the facilitated learning
analysis (FLA) process to review “unintended outcomes”
(such as a prescribed fire escape, injury, or fatality) in 2013
[67]. The FLA paradigm seeks understanding and improving
future performance, not fixing blame retrospectively. Efforts
center on learning from “unintended outcomes”in dealing with
wildfires or prescribed fires, though there is recognition that
learning from “normal”events or events that go well is also
valuable.
Simultaneously, a federal research effort sought to under-
stand the content and effectiveness of learning, specifically
from reviews of prescribed fire escapes, through a series of
dialogs with managers [43]. The 60+ participants representing
all levels of federal agencies with fire management responsi-
bilities described relatively consistent advances in both con-
ceptual and cultural practices related to preparation and
reflection. For instance, while not required by policy, some
units had adopted the concept of “pre-mortems,”a process
discussed by Klein [] as a way to anticipate how a prescribed
fire might go wrong in advance of ignition, thus allowing
operators to pre-identify response options and avoid an unin-
tended outcome (preparation). By the mid-2000s, many units
were conducting “after-action reviews,”astructured
debriefing (reflection) process developed by the US military
and adopted by wildland fire operators to assist with organi-
zational learning [68].
At the same time, the review pointed out gaps in effective
Capture,Retention,Transfer and integration of lessons, in-
cluding the need for systematic capture of essential informa-
tion on prescribed fire escapes and subsequent trend analyses
to describe patterns, pattern development, and potential miti-
gations (capture); processes to quickly incorporate insights
into practice (retention); and training and mentoring programs
(transfer). Revision of the Interagency Prescribed Fire Guide
[69] incorporated many insights from this review (integra-
tion), including providing “lessons learned”boxes as tips for
each section of the guide, and described a rich array of review
types, including “Before Action Reviews,”similar to the pre-
mortem concept.
Since 2013, the US federal wildland fire community has
continued to develop policy and procedures that institutional-
ize the FLA or a similar learning-based process (change in
latent organizational context), developing new routines in
which, in our case, prescribed burn teams and peers gather
to learn from the event. The FLA, and its companion the
learning review (LR), which is geared for more serious out-
comes like fatalities [68], focuses on the events immediately
prior to the “unintended outcome”and the conditions, actions,
and context that seem to contribute. Learning, and sense-mak-
ing, occurs through guided story-telling as each participant
shares their experience. Technical skills are assessed by ensur-
ing prescribed burn personnel hold appropriate certification.
Equipment performance is evaluated by a subject matter ex-
pert referencing appropriate policy and/or equipment specifi-
cations. Procedural skills are assessed by checking whether
Curr Forestry Rep (2020) 6:41–59
48

planning documents are complete and follow approved pro-
cedures. Burn implementation is assessed through the collec-
tive discussion. This process is now guided by a growing
cadre of subject matter experts who have completed an ap-
proved training course overseen by a steering committee. When
a review is requested or required, this organizational unit pulls
together the trained peer cadre and provides coaching to that
cadre as they guide the local unit through their learning. The
review cadre produces a written document that is transmitted to
the local unit and posted on the interagency WFLLC website
(and increasingly, multimedia products).
The subsequent sections here draw primarily from the 34
published reviews (although only nine are FLAs, one is a
Rapid Lessons Shared, the majority have a learning orienta-
tion), but also wrap in other known activities that do or could
assist.
Prepare
Preparatory actions such as pre-mortems can identify during-
incident dynamics to watch for and allow the crew time to pre-
identify potential and desired responses. Reviewing previous
escapes and lessons learned from those is another excellent
technique to help a prescribed burn team prepare. These can
be used to develop “triggers”or “trigger points”(events or
conditions) which if encountered would prompt specific types
of response.
Oneofthereviewsnotedthevaluetotheprescribed
burn team of conducting a “pre-mortem”; an additional
six noted the value of these and similar exercises. The
current review paradigm places primary emphasis on
first-person and team learning. Reviews indicate these in-
dividuals do seem to be extracting explicit lessons from
theevents,thoughlessonstendtobewordedinthethird-
person, such as “identify off-site resources”and it is un-
clear who and how these valuable suggestions should be
used in future preparations. In most cases, fuels, weather,
and fire behavior are captured and presented in detail, and
sometimes analyzed, but the connection to how this
should play into building awareness and impact for future
operations is not always made clear. Some documents
comment on whether the decisions made by the pre-
scribed burn team seemed appropriate. The majority (18)
of the reviews includes specific recommendations
4
or di-
rectives, most targeted at their own level of operation or
immediate internal partners/levels, which if acted upon
would likely have a significant positive impact on future
operations. A few note a need for action at broader orga-
nizational levels. However, even when directed at their
own levels, it is often unclear who the appropriate person
is to ensure follow-up on an insight, encouraged activity,
or recommendation. There appears to be no consistent
process or central entity or avenue for collecting, tracking,
or monitoring follow-up. Some mechanism to ensure
monitoring of review outcomes to determine efficacy of
resultant changes would undoubtedly contribute to im-
proved future preparations.
Documentation and analysis of social and human factors
remains at the topical level—such as need for additional com-
munication. While possibly adequate for local improvement,
if acted upon, there is generally insufficient information pro-
vided in the reviews to guide deeper analysis of human inter-
actions and/or organizational process (e.g., beliefs, culture, or
team dynamics in either tacit or explicit domains), such as
would be valuable for broader organizational learning (more
on this later). We are aware that some areas incorporate a
recent review into annual “refresher”courses required for cer-
tain fire positions, but our understanding is that this is locally
determined and organized. This is an intuitive mechanism for
integrating lessons and likely could be enhanced with broader
coordination.
Another type of preparatory tool has been proposed in
Canada. Jin and McRae [40] developed the Prescribed
Fire Excursion Index (PFEI) to help Ontario prescribed
fire managers identify the factors other than traditional
weather prescriptions that may lead to an escape.
However, as the designers note, the PFEI is “an interim
product”which “has certain limits”—a small dataset, and
poor documentation for some incidents, and would benefit
from reporting using a better definition of a prescribed
fire escape.
Do
Prescribed fire escapes may be seen as audits of response
repertoire [56•]. In this context, audits take the form of spot
fires, slop-overs, increases in fire behavior (rate of spread,
fireline intensity, crown fire initiation), sudden changes in
wind speed and direction, and/or fire spread direction, fuel
condition, and breakdowns in equipment and/or communica-
tions. Barton and Sutcliffe [70] found that planned or un-
planned micro-disruptions (such as any of the above) during
an operation can be essential in helping a group recognize the
need to adjust operations to changing conditions. While in-
stances of micro-disruptions were identified, this is not a con-
sistent activity. Increasingly, reviews recognize the inevitabil-
ity of human error—particularly individuals missing signals
that are identifiable in retrospect, but which go unnoticed for
any of a variety of reasons. Because of this, there is an
4
The 2018 FLA Implementation Guide cautions against trying to make too
much of a single data point (any single event), and falling into the trap of
causality, which often leads to creation of “fixes”in the form of system-level
changes via recommendations [67].
Curr Forestry Rep (2020) 6:41–59 49

increasing frequency of recommendation for prescribed burn
teams to pre-identify how to build in “slack”and “redundan-
cy”to maximize the opportunity for someone, somewhere to
notice and to feel encouraged to share this information in
sufficient time for the organization to adapt.
Outside of considering lessons and recommendations in
review documents as tools, existing requirements and best
practices prompting prescribed burners to step back during a
burn to review prescription parameters, complexity ratings,
etc., can and do provide additional types of micro-disruptions.
Triggers, discussed earlier, are indicators of the potential for
the onset of micro-disruptions. Ensuring a culture of psycho-
logical safety, in which anyone feels comfortable asking ques-
tions or speaking up, is a contextual feature that can enable
verbal micro-disruptions—‘what’s going on here?’. As one
FLA team stated:
Our recommendation is to acknowledge the complexity
of our environment and the limitationof our abilities and
to use this information to build room for the inevitable
error to exist without consequence. This could take the
form of consciously practicing consistent feedback in
order to develop a shared mental model of operations
and the environment. How “good”is your Situational
Awareness? How can you allow for the inevitable miss-
ing information or misperception of the environment?
[71,p.27]
Another recent innovation that spans from doing to
transfer is the Rapid Lesson Sharing process. Developed
and coordinated by the WFLLC, these are intended to
quickly capture and disseminate trends and insights during
a fire season, using similar data collection processes as
FLAs.
Considering learning in the broader contextual frame, sev-
eral organizations are emphasizing learning-through-doing by
creating opportunities for practitioners to gain experience
burning alongside more experienced or seasoned prescribed
burners. The US National Interagency Prescribed Fire
Training Center (www.nifc.gov) annually hosts combined
classroom and field sessions to simultaneously provide
training and accomplish prescribed burns. The Nature
Conservancy, a non-profit organization, has developed and
is sponsoring prescribed fire practitioner “exchanges”
(TREX) worldwide in which practitioners can learn experien-
tially from experts and mentors while conducting project
burns [www.conservationgateway.org;72]. The Coalition of
Prescribed Fire Councils, another non-profit organization in
North America established in 2009, also seeks to “promote the
appropriate use of prescribed fire for enhancing public safety,
managing resources, and sustaining environment quality
(www.prescribedfire.net). It serves states and local areas.
These organizations are actively working to build both tacit
and explicit expertise to ensure success of burns and sufficient
capacity for increasing prescribed fire in a time of significant
loss of expertise due to retirements.
Reflect
Of the 34 reports reviewed (Table 2), recommendations
and lessons learned were identified by both participants
and review teams (which sometimes included Line
Officers as well as prescribed burners). Eighteen reviews
included specific recommendations; most frequently, these
were offered by the review team only. Sixty-two percent of
the reports reviewed noted either communications or other
human factor-related lessons covering the spectrum from
project planning to implementation phases. Many encour-
aged more active curiosity and questioning; examples
include:
&Conducting “what-if”conversations; continuously
updating understanding of conditions
&Checking assumptions (such as about fuel receptivity
within the prescribed burn unit, over time, and in fuels
adjacent to but outside the intended project boundary)
&Checking the effectiveness of communications, actively
speaking up
&Recognizing who has expertise or familiarity with the unit,
procedures, or knowledge of the fuels and accounting for
them
&Ensuring mindful attention to conducting the burning op-
eration and adequate staffing until the burn is complete
&Seeking ways to build more “slack”into the system to
allow for small errors (such as reducing dependencies
and connections); see Weick and Sutcliffe [73] for addi-
tional ideas
In the absence of understanding how these same orienta-
tions occur or not on successful prescribed burns and on sup-
pression incidents, it is difficult to know whether these are
local or general lapses in attention to detail. However, none
of these are unique, and all in some way or another indicate a
lapse in best practices—be it of a formal procedure or an
informal team practice [cf. Maupin 38,39].
Despite the obvious evolution in reflective learning prac-
tice, some managers observe that: “these reviews are really
expensive and time-consuming, yet they seem to all say the
same thing over and over. Why do we keep doing them?”This
is an excellent question, one answer to which rests on who is
the target of learning? Current documentation and communi-
cation practices do not provide consistent or sufficient details
to support meta-analysis. Occasionally, a region will review a
suite of prescribed fire escapes, but this is not a routine prac-
tice. At the local unit level, some reviews have caused fire
managers to change the way they operate—for instance, fully
Curr Forestry Rep (2020) 6:41–59
50

committing contingency forces to an incident rather than sim-
ply putting them on notice in case of need. There is significant
variation across reviews, with some clearly identifying what
change is desired and who holds the keys to that change, while
others are vague. Black et al. [43] found that the review teams
and the participants were the primary beneficiaries of these
efforts, thus potentially worthy as a workforce development
opportunity; however, that still seems to leave a lot of learning
yet to be captured. Another useful direction would be to con-
sider integrating a more academic perspective to add rigor to
reviews. As noted earlier, current management and learning
paradigms benefit from conceptual and applied theorists.
Klein et al. [74] and McLennan and colleagues [75]drawfrom
psychology to describe varieties of anticipation, and then use
this to consider drivers of behaviors that are integral to safety
and decision-making. Similarly, Constantinides [76]buildson
Turner’s[77] consideration of “failures of foresight”to ana-
lyze a disaster. Considering the evolution of prescribed fire
escapes through such lenses could prove enlightening and
valuable.
Capture, Retain, Transfer—Explicit Knowledge
Establishment of the LR and FLA processes (as policy and as
a consistent replicable process supported by consistent train-
ing and credentialing) does much to institutionalize organiza-
tional learning routines to capture lessons. While necessary, in
and of itself, it does not ensure transfer or integration of les-
sons into futurebehavior, at local or organizational levels. The
processes focus on sense-making,story-telling, and experien-
tial knowledge. To date, there is no systematic analysis or
rigorous evaluation of these interpretations and insights to
deepen learning (analysis), particularly at an organizational
level. Nor is there evidence of advances in retention and trans-
fer (integration) of lessons identified to improve operational
performance. Post-review knowledge transfer remains vague
and unstructured; though reviews offer ways others may learn
from their experiences, sometimes very clearly and specifical-
ly. Unfortunately, we found no policies or processes that en-
able, require, or consistently guide integration of these in-
sights and recommendations into future preparatory activities.
Considerable interagency effort has been devoted to diffus-
ing knowledge and innovation through networks, but this has
mostly focused on databases to aid in building libraries (reten-
tion). For example, the interagency WFLLC, which was
established in 2002, seeks to connect practitioners with each
other electronically, and captures, retains, and makes review
documents readily accessible. Additionally, regional, federally
funded “Fire Science Networks”facilitate exchange of new
science through place-based professional communities of
practice.
One of the most intuitive settings for transfer of learning is
during spring training courses (such as the Burn Boss
Refresher, see www.nwcg.gov/publications/training-courses/
rt-300). Courses generally include review of some event or
FLA; however, it is apparently an ad hoc process, with the
specific event determined by local leaders. Broader
organizational and leader support to institutionalize this
process (i.e., attain consistency through formal policy or
informal community of practice) might assist.
Occasionally, agency policy is updated as a consequence of
a review (such as after the 2012 review); however, the process
depends upon volunteer member committees under the US
National Wildfire Coordinating Group, an interagency body
whose actions are non-binding until each agency specifically
adopts recommendations. The scant evidence of transfer of
lessons from one burning unit to another, or resulting changes
in larger organizational behavior, processes, and routines, sug-
gests that there are opportunities to further improve organiza-
tional learning.
Capture, Retain, Transfer—Tacit Knowledge
In addition to explicit technical and systems knowledge, spe-
cific domain understanding is critical for success. The ability
to make nuanced judgments is a form of expertise most often
developed experientially and is often tacit rather than explicit.
The training paradigm in US planned (prescribed) and un-
planned (wildland) fire programs combines classroom learn-
ing focused on technical and procedural skills with on-the-job
training focusing on building tacit and explicit experiential
skills. Personnel fully qualified in a trainee’s specific task
are engaged as coaches who evaluate the trainee’s perfor-
mance. However, there are no training or other qualifications
required in order to function as a coach/trainer and no over-
sight; thus, in addition to having no common bar or expecta-
tions for coach/trainer, there is limited ability to insert new
insights or culture via this mechanism. In 2016, The Nature
Conservancy’s TREX program formalized a “coaches net-
work”which might provide some ideas for improving federal
leadership training.
It is widely felt within the wildland fire community that
it is losing experienced prescribed fire managers faster than
we are developing them. In combination with increasingly
altered fuel and weather interactions, which pose novel fire
environments to both experienced and novice practitioners
alike, capacity development is an arena that needs addition-
al attention (cf. Moriarty et al. [42] for consideration of a
specific new fuel type created by mountain pine beetle
infestations).
Victoria, Australia
Contextual factors continue to evolve, requiring ongoing ad-
aptation and learning if organizations wish to maintain their
prescribed burning capability. It is notable that unlike the
Curr Forestry Rep (2020) 6:41–59 51

USA, Australian state and territorial governments play a rela-
tively larger role in fire management and that Australia does
not have the same types of federal agencies present that the
USA has (e.g., the Forest Service and the Bureau of Land
Management).
Following the catastrophic 2009 Black Saturday fires,
the Victorian Bushfires Royal Commission (VBRC)
made 67 recommendations for fire management in
Victoria [78]. The VBRC found that there had been
inadequate prescribed burning conducted on the 7.7 mil-
lion ha of Victorian public lands. It recommended that
the State commit to a rolling program of prescribed
burning to achieve a minimum target of 5% of public
land each year. This recommendation set in motion the
requirement for the State to achieve a threefold increase
in its prescribed burning program on public land. But
since 62% of Victoria is in private ownership, there is a
need for a whole-of-government approach to conduct
prescribed burns more strategically across land tenure,
to include private land also.
Other Australian land and fire management agencies paid
close attention to the VBRC recommendations, recognizing
that there was a national need to address how prescribed burn-
ing programs were delivered [79]. This led to the establish-
ment of a national initiative to align and improve prescribed
burning practices, which developed into the National Burn
Project (NBP, 2011-2017), co-funded by the Australian
Attorney-General’s Department and AFAC
5
member agen-
cies. The NBP’smissionwas“To bring together inter-related
aspects of prescribed burning in Australasia to design guiding
frameworks and principles for a more holistic and consistent
approach to prescribed burning”[80]. The NBP worked close-
ly with agencies and researchers to review practice and evi-
dence. The NBP has published various resources and run
workshops toenablethe sector to improve knowledge sharing,
learning, and practice [5,81–83]. In July 2017, the Centre of
Excellence for Prescribed Burning (CoEPB) was established
to continue this work [aidr.org.au/programs/centre-of-
excellence-for-prescribed-burning/;84–87].
High-profile prescribed fire escapes such as the 2011
Margaret River Fire in WA (see Sidebar) and the 2015
Lancefield-Cobaw Fire in Victoria have attracted consid-
erable scrutiny and influenced prescribed burning poli-
cies and practices [20,32,88–92]. Escapes from
planned burns also continue to occur on private lands,
and unfortunately, sometimes in clusters that have
caused considerable damage [16•,32,93].
In Victoria, the Lancefield-Cobaw Fire escape led to an
independent investigation making 22 recommendations to
improve the management of planned burns by DELWP [32].
These recommendations focused on:
&Building a better identity for fire management and planned
burning on public land so that it can develop more robust
and sustainable relationships with the local communities
[94]
&More active and meaningful community engagement
&Creating a structure to better integrate burn planning and
operational implementation
&Improving systems and processes to ensure risk assess-
ment to reflect the broader landscape and that appropriate
resourcing is provided to meet that risk
&A thorough review of the risk management and approvals
process, ensuring that risk assessments and outputs are
clear, current, and useful
One of the interesting features of these recommendations is
that in addition to tackling prescribed burn operational and
process issues, they address broader organizational structure,
engagement, identity, and relational issues.
Prepare
Victorian agencies continue to refine and deliver a range of
training programs to develop fire management and prescribed
burning personnel, particularly to develop skills to use the
various systems, processes, and knowledge of key concepts
and good practice.
In addition, changes in policy, planning, and decision-tools
as a consequence of reviews have led to increased attention on
effectiveness and acknowledgment of risk. Following the
Lancefield-Cobaw prescribed fire escape, DELWP moved
away from a purely hectare-based target and developed the
“Safer Together”policy [95] that specifies a more strategic
approach to the use of planned burning to more directly reduce
risk of impact of wildfire on the community. This framework
helps DELWP to assess the number of hectares burnt, the
effectiveness of the program [9], as well as to prioritize
planned burns to ensure that the residual risk for the state
remains at or below 70%.
6
In early 2016, DELWP introduced the Planned Burn Risk
Assessment Tool (PBRAT) to support improved decision-
making [96]. The tool is aimed at providing a more consistent
peer-reviewed and risk-based approach for planning pre-
scribed burns on public land [97]. However, an internal review
observed that the fire management risk assessment processes
were imperfect, failing when there were (i) unforeseen circum-
stances, (ii) rapidly changing circumstances, (iii) time-critical
decisions required, and (iv) need for expert judgment [98].
5
AFAC: AustralasianFire and EmergencyService Authorities Council (www.
afac.com.au/).
6
“Residual risk”is 100% if none of the land has been burnt. It is not possible
to reduce this risk to zero. A benchmark of 70% is seen as a practical figure.
Curr Forestry Rep (2020) 6:41–59
52

This heightened the requirement to improve learning in order
to build expertise. The review concluded that there were im-
portant gaps in analysis of insights, links to training, and dis-
semination of learnings to relevant staff. Reports of prescribed
fire escapes in particular were rarely communicated to all of
the relevant staff. This latter problem is beginning to be ad-
dressed via a Rapid Lesson Sharing approach (see share.em.
vic.gov.au/wizard).
Do
Learning-by-doing is an important principle for Australian
land and fire management agencies. Victorian agencies use
the Centre for Creative Leadership’s 70:20:10 model of
learning for training fire management personnel [99].
This model proposes that 10% of learning is achieved
through formal training (e.g., classroom and online), 20%
results from learning from others (e.g., peer feedback,
coaching, and lessons learned), and 70% occurs through
on-the-job practice and problem-solving exercises. This
raises the question of whether adequate resources and
training are being provided to support the coaching and
mentoring envisaged in this model [100]. An aging work-
force and the loss of some of the most experienced prac-
titioners further exacerbates this challenge. Agency support
for coaching and mentoring personnel involved in fire
suppression activities appears to be somewhat greater than
it is for personnel involved in prescribed fire management.
The AFAC [85] review of training for prescribed fire in
Australia noted that just two jurisdictions (South Australia
and Tasmania) identified mentoring as part of their pro-
grams. The review also found that most agencies were
struggling to manage their prescribed fire instructors’
teaching workload so that they could also maintain their
practical burning skills.
Reflect
After-action reviews, pre-mortems, and staff rides are used
by Victorian fire and land management agencies to help
capture opportunities to reflect and learn and to improve
performance of individuals and teams. Although these
tools are well known, there is some concern that these
are not consistently used across Victorian agencies, and
that at times, personnel may be reluctant to speak up in
these sessions. This observation is supported by Stack and
Owen’s[101] survey of agency personnel as part of their
Cobaw
7
Fire staff ride evaluation. The authors reported
that 40% of survey respondents said that their agency
Sidebar Image NASA Earth observatory satellite image showing planned
fire (BS520 and BS255—purple) and escaped fire (red) perimeters of the
Margaret River Bushfire (November 2011)
The origins of the November 2011 Margaret River Bushfire were two
prescribed fires at Ellenbrook (BS520, 722 ha) 13 km north-west of the
town and at Prevally (BS255, 131 ha) just to the west. These prescribed
fires were undertaken to reduce the risk to nearby communities given that
there had been an extended absence of fire in these forested areas. The
Ellenbrook prescribed burn was first ignited on September 6th 2011 in
order to create a burnt edge around the perimeter of the planned burn area.
Despite several subsequent attempts, the perimeter of the Ellenbrook
prescribed burn could not be secured because of high fuel moisture levels.
On November 20th, the Prevally prescribed fire was commenced and the
following day the Ellenbrook prescribed fire received further ignitions. These
burns were undertaken with the knowledge that forecast weather would
become unfavourable on November 23rd. The judgement of the prescribed
fire managers was that these fires could be completed and made safe in less
than 3 days. Despite several attempts, 1.5 km of the south-western perimeter
of the Ellenbrook prescribed fire remained unsecured. No spot forecasts from
the Bureau of Meteorology for the Ellenbrook prescribed fire were obtained
by the land management agency on either November 21 or 22. On November
23, actual weather conditions were more extreme than forecast with northerly
winds of 37 km/h observed rather than the forecast winds of 27 km/h. Various
other events exacerbated the situation including a misunderstanding of a
spotter aircraft’s concerns regarding smoke emanating from the Ellenbrook
prescribed burn on the afternoon of November 22 and resourcing issues for
patrolling the Ellenbrook fire. It appears that either later on November 22 or
the morning of November 23, the Ellenbrook prescribed fire escaped and
burnt south towards Margaret River. The Prevally prescribed fire flared up
and escaped on the morning of November 23. The special inquiry [20] notes
a range of additional factors important in this prescribed fire escape. For
example, the attraction and retention of experienced staff, constant turnover
of staff, and the long hours and drive distances adversely affecting judgement
of prescribed fire staff.
The Margaret River Fire destroyed 41 houses and heavily disrupted
tourism central to the region’s economy. The escaped fires burnt a total
of 3400 ha, almost four times the area of the plan for the prescribed fires
(see Keelty [20] for further details).
7
In 2003, a prescribed fire escaped from the Cobaw State Forest, an incident
that pre-dated the 2015 Lancefield-Cobaw fire escape. The 2003 escape
formed the basis of a staff ride developed in 2012 [101].
Curr Forestry Rep (2020) 6:41–59 53

buried what happened when things went wrong, and 28%
said that blame was assigned to individual people.
In response to the Lancefield-Cobaw Fire escape, the
Victorian government also asked the State’s Inspector-General
for Emergency Management (IGEM) to review other pre-
scribed fire escapes. IGEM has published two reports analyzing
the issues around escapes and identified common themes and
potential learnings for the agencies concerned [97,102].
Capture, Retain, Transfer—Explicit Knowledge
Several of the items discussed in the preparing to learn sec-
tion are products that enable Victorian organizations to cap-
ture, retain, and transfer explicit knowledge. For example, the
Safer together policy and the PBRAT put in place processes to
more systematically assess risk, increase checks and balances,
and provide guidance on good practice. Similarly, the inde-
pendent investigation on the Lancefield-Cobaw Fire escape
and by IGEM on subsequent prescribed fire escapes makes
explicit the potential opportunities for learning.
Transfer of learning typically occurs during training
courses such as Burn Officer in Charge [85]. Courses
may include review of some previous prescribed fire
escaped case studies; however, it is apparently some-
what ad hoc, with some case study materials and field-
work determined by the instructor responsible. There
appears to be limited evidence of transfer of lessons
from one burn unit to another or resulting changes in
larger organizational behavior, processes, and routines
suggesting there are further opportunities for improved
learning. A prescribed burn manager neatly observed
that “burns escape for the same reasons they have al-
ways escaped.”
At a national level, AFAC, NBP, CoEPB, the Bushfire
Cooperative Research Centre, and the Bushfire and
Natural Hazards Cooperative Research Centre have pro-
duced a variety of practice guidelines and research to
help Australian agencies improve their prescribed burn-
ing capability. Owen’s[59•] review of the uptake of
research found that within agencies, there were different
perceptions between senior managers and front-line staff
as to how effective the organization perceived been in
disseminating advances in research. The research sug-
gested that front-line staff perceived lower levels of ef-
fectiveness of how research is disseminated, and that
there were different levels of research utilization matu-
rity between agencies.
A further issue is that explicit knowledge learned from a
prescribed fire escape is taken up mainly by those directly in-
volved and only partially distributed to the rest of the organiza-
tion. For example, in Victoria, prescribed burn bosses or con-
trollers rarely hear about or participate in learning opportunities
beyond their local area, such as a community of practice with
their prescribed burn planning and operational colleagues.
Capture, Retain, Transfer—Tacit Knowledge
Fire and land management agencies rely heavily on the tacit
knowledge oftheir moreexperienced staff to plan and manage
prescribed burning operations. English’s[103•]reviewoftacit
knowledge transfer in Victorian agencies highlighted the need
for agencies to understand (i) what tacit knowledge is and (ii)
how it is used, withheld and shared by individuals within an
organization. English [103•] proposed that the Victorian fire
and land management agencies need to consider four changes
in their operations to better foster knowledge exchange and
development:
1. Developing new systems and resetting organizational
norms to foster a more egalitarian workplace that supports
interaction and sharing of information between practi-
tioners, researchers, and community (the non-fire agency
population)
2. Using new forms of operational analysis that explore how
staff use and develop their knowledge in context
3. Reconsidering the current knowledge exchange processes
(e.g., after-action reviews and debriefs) to better recognize
and leverage practitioners’tacit knowledge
4. Adopting an investigative approach that better recognizes
the central role tacit knowledge plays in dynamic situa-
tions such as bushfire decision-making
English [103•] suggests that the USA’s FLA process may
be a suitable approach.
ForeachofthesixOLdimensions,wefoundanumber
of similarities and a few notable points of difference. The
OL emphasis for both countries over the past decade has
focused on the middle dimensions of doing, reflecting, and
capture of explicit knowledge. Significant advances contin-
ue to be made. The areas of greatest challenge appear to
be in closing the loop and attending to development of
tacit knowledge.
Concluding Comments
On a number of counts, the USA and Australia face similar
challenges and issues in ensuring effective organizational
learning with regard to avoiding prescribed fire escapes. Not
only is it an ongoing challenge to effectively adapt to evolving
and dynamic bio-physical and societal environments; each
organization is itself a complex, multi-level system shaped
by its mission, traditions, formal and informal processes, and
social factors. It should come as no surprise that while we find
Curr Forestry Rep (2020) 6:41–59
54

land and fire management agencies working hard to improve
their learning—with some success—we also find significant
areas for improvement. It is also interesting to observe that the
Australian entities have taken a more centrally coordinated
top-down approach to reviews and dissemination. The US
experience has been a more bottom-up approach. Both have
legitimacy and value; perhaps one future step would be to
exchange best practices.
Based on our assessment of available review documents,
we highlight four areas we believe require specific attention if
fire and land management agencies are to improve prescribed
fire performance. These include (i) developing a richer orga-
nizational learning culture, (ii) developing structures and pro-
cesses to support lesson sharing, (iii) addressing the increasing
skills-gap, and (iv) improving non-technical skills and human
factors training.
Improvingorganizationallearninginprescribedfire
would have obvious spin-off benefits in other areas of
activity including wildfire response and organizational
adaptation to change.
Developing a Richer Organizational Learning Culture
We note that US agencies appear to be better placed
than their Australian counterparts in producing and
nominally distributing materials to support lesson shar-
ing, particularly those generated by prescribed burn
team participants. However, agencies in both countries
still struggle to obtain real traction in sharing and in
learning—that is, fully integrating lessons into future
operations, suggesting the need to develop stronger pro-
cesses to institutionalize effective transfer and tracking
routines.
As alluded to earlier, although the LR and FLA pro-
cesses and documentation represent real progress, there
is more to organizational learning than what has cur-
rently been realized. There are both local and collective
aspects. At the collective level, organizations are unable
to retain the very real lessons—both local and
organizational—developed during the reviews due to
lack of process for ensuring these are shared and acted
upon. The ability to discern patterns or trends from
prescribed fire reviews—somewhat absent in the USA’s
2012 review mentioned earlier and constrained as noted
in this current review—is virtually impossible without
consistency in review documentation (format, type of
information, and repository). As well, more rigorous as-
sessment of the human element, based on social science
theory, such as communications, psychology, high reli-
ability, teaming, risk assessment, would be valuable for
both local and collective learning.
Edmondson’sresearch[60,63•] underscores how organi-
zational learning is highly dependent on a psychologically
safe climate in which people feel free to voice their concerns.
This speaks directly to local work environments and supervi-
sory behaviors. Evidence from both the USA and Australia
indicates that while the new processes have started to surface,
agencies still have some way to go when it comes to devel-
oping a richer understanding of how unintended outcomes
develop (indicating progress in providing more psychological
safety). Willingness to speak up is just the first step—the test
is how leaders and the wider organization respond [63•]. It is
also equally well established that people stop speaking if
nothing changes as a consequence of their effort [63•].
Developing Opportunities to Support Lesson Sharing
In the USA and Australia, agencies could benefit from engag-
ing in deliberate and sustained effort in any of a variety of
opportunities to support sharing lessons. Evidence exists that
lessons are available and shared to some degree at the small
group and team (temporally and spatially local) level. Yet as
one prescribed burn practitioner in Australia was to “note, the
lessons do not get to those who need them, especially upper
management and prescribed burn controllers.”There is much
room for improving the link between capture of distributed
insights and broad integration into organizational practice
(transfer, preparation).
Address the Skills Gap Between Time Needed to Build
Requisite Expertise and Pending Retirements
The expertise required to successfully plan, conduct,
and oversee prescribed burning operations takes time
to build. Most US and Australian agencies are losing
these skilled practitioners faster than they can develop
their replacements. Senior practitioners observe that it is
hard enough to find an experienced practitioner to over-
see prescribed burns let alone perform coaching or
mentoring functions. Progress in the dimension of tacit
knowledge development (capture, retain and transfer) is
adverselyaffectedbyamixture of retiring expertise,
limited capability to resource the assumed learning by
doing approach, and perhaps an underestimation of the
organizational and practical challenges in achieving ef-
fective tacit knowledge transfer required to develop
highly competent prescribed fire practitioners and teams.
We note a couple of ways agencies can deliberately
seek to tighten this gap. Perhaps most exciting are the
multi-agency prescribed fire practitioner workshops in
which experienced burners work alongside of and men-
tor newer burners as they conduct burns. Another com-
plementary option might be to take a page from other
sectors which retain expertise through adjunct and emer-
itus roles or by engaging retired senior practitioners and
managers to act as mentors [104,105].
Curr Forestry Rep (2020) 6:41–59 55

Improve Non-Technical Skills and Human Factors
Training
Reports on prescribed fire escapes focused largely on the op-
erational and procedural aspects of the event. There has been
more limited commentary on the human factors aspect of
events. Research on high-reliability organizations points to
non-technical skills—the “soft”skills of human dynamics—
as central to safe and effective performance and learning [106,
107]. US and Australian organizations could expand efforts to
embed emotional/social intelligence, human factors, and non-
technical skills into training and development programs.
There are efforts to build upon these programs such as
AFAC developing online human factor modules [108] and
the inclusion of team member skills in AIIMS2017 [109],
inclusion of some interview training for the FLA process,
some use of pre-mortems, and staff rides at the operational
level [101,110,111]. Identifying critical skills and competen-
cies, then ensuring integration into training and development
could greatly assist. Such skills would enable prescribed fire
personnel to better understand their own cognitive and emo-
tional styles as well as increase ability to be aware of and
better manage the adverse effects of stress, fatigue, cognitive
biases, and social influences on themselves and others.
In conclusion, there have been significant advances in
learning, and yet more remains to be done. It is hoped that
experiences in the USA and Australia may be used to further
enhance organizational learning capabilities to continue to im-
prove prescribed burning operations.
Acknowledgments We would like to thank Dr. Marty Alexander for his
encouragement to conduct this review and his guidance throughout. We
also whole-heartedly thank two anonymous reviewers for their very help-
ful comments and suggestions.
Compliance with Ethical Standards
Conflict of Interest All authors declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent This article does not
contain any studies with human or animal subjects performed by any of
the authors.
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