Better: A Surgeon's Notes on Performance

by Atul Gawande

a 1949 Montana forest fire that engulfed a parachute brigade of firefighters. Panicking, they ran, trying to make it up a 76 percent grade and over a crest to safety. But their commander, a man named Wag Dodge, saw that their plan wasn’t going to work. So he stopped, took out some matches, and set the tall dry grass ahead of him on fire. The new blaze caught and rapidly spread up the slope. He stepped into the middle of the burned-out area it left behind, lay down, and called out to his crew to join him. He had invented, on the spot, what came to be called an “escape fire,” and it later became a standard part of Forest Service fire training. His men, however, either thought he was crazy or never heard his calls, and they ran past him. All but two were caught by the inferno and perished. Inside his escape fire, Dodge survived virtually unharmed. As Berwick explained, the firefighters’ organization had unraveled. The men had lost their ability to think coherently, to act together, to recognize that a lifesaving idea might be possible. This is what happens to all flawed organizations in a disaster,