On June 30, 2013 a crew of 19 firefighters was killed by the Yarnell Hill Fire near Yarnell Arizona. Recently a report was released on an investigation of this event. In my view the report is seriously flawed, showing an undue reluctance to criticize the decisions that led to 19 deaths. The report claims it is trying to avoid hindsight bias, the tendency to label decisions as wrong when they work out badly even if they were actually reasonable under the circumstances. This is a commendable goal but it has to be balanced against the need to identify avoidable mistakes. Simply refusing to judge decisions is not the proper balance.
The report refers to decisions made by the crew and speculates about the thinking behind them. But I expect the crew as a whole was not making decisions, instead the decisions were made by the crew's leaders (who appear to have been two men which the report does not name). If 19 people are killed in plane crash the investigation will naturally focus on the pilots. What was their training, experience, reputation? Similarly one would expect this report to discuss the background of the fire crew leadership but in fact it provides no information at all. Also in recent years there has been much attention paid to cockpit dynamics. For example if the pilot makes a mistake does the co-pilot feel free to object. Again this report does not discuss the analogous fire crew dynamics at all.
The fire crew was killed while apparently attempting to move from one safe area to another (perhaps as the report speculates because they felt the second area would leave them better positioned for further firefighting efforts, although it should be noted the overall leadership did not expect or particularly want them to do this). In doing so they chose a route that placed them in mortal danger. Initially they moved on a two track road along a ridge. This seems to have been reasonably safe at least at first as they had a view of the fire and various retreat options if it moved towards them. However they then left the road (which would have eventually taken them to their apparent goal) to descend off the ridge through a box canyon directly towards their destination (a ranch with a cleared area). Although this was a shorter route than continuing along the road it probably wasn't quicker as it was much heavier going. The report speculates that the ranch appeared closer than it was and that they didn't realize how slow the going would be. The real problem however was once they left the ridge they lost sight of the fire and (according to the report) the ability to perceive the wind shift that drove the fire towards them. By the time they realized they were in danger it appears it was too late to do anything. The report lists some of their options at the point they left the ridge but does not discuss one possibility. Why didn't they leave a scout on the ridge to keep watch on the fire and warn them if it started to move towards them? They had utilized a scout earlier in the day in what seems like a less dangerous situation so why not here? The report doesn't discuss this.
The report doesn't want to admit that any mistakes were made. This makes it hard to identify problems and make improvements going forward. The report's view is that firefighting is inherently dangerous and that these 19 deaths were just one of those things. I am not convinced.
Added 12/25/2013: I fixed the link to the report. Some other material including a video was also released.