# Presentation: 285324

## 1. Broaden your options for dealing with situations that can surprise you.
2. Provide ideas that help you rethink the consequences of your current ways of
working.
3. Provide some organizing practices that can increase your awareness of small
mistakes that can grow into large crises.
4. Help you build your own mental model of how you might use some of the HRO principles in doing Tech Reviews.

**1. Broaden your options for dealing with situations that can surprise you.**
**2. Provide ideas that help you rethink the consequences of your current ways of**
**working.**
**3. Provide some organizing practices that can increase your awareness of small**
**mistakes that can grow into large crises.**
**4. Help you build your own mental model of how you might use some of the HRO principles in doing Tech Reviews.**

## Intended Purpose

- To help us improve our wildland
- prescribed fire and fire use programs by
- exploring High Reliability Organizing
-   Apply “HRO” principles in Rx Fire Burn Plan Tech Reviews.
-  This discussion is part of an organized effort
- to lessen the chance of future prescribed fire
- escapes and to increase the chances of
- replicating our successes.
-  It is intended to provide you with some tools—relevant to the
- entire wildland fire management
- community—to every workshop participant.

## HRO Principles for Tech ReviewsAppendix B in the Burn Plan

## HRO’s and Burn Plan Reviews

- As burn plans are written, there is a tendency to underestimate the complexity of inter connected events.
- If these tendencies go unchecked they can lead to unreliable performance, escaped fires, injuries or worse.
- HRO’s overcome error when people with varied experience apply a set of resources to contain the unexpected.

## Setting the Stage

- Why is HRO/Mindfulness important to you?
- Less room for decision error under pressure.
- It is easy for even the most experienced fire organizations to go “mindless”.
- Safety degrades-it constantly needs to be replenished.
- Trial and error is a poor way to learn.
- Resilience-the skill and capacity to be robust under conditions of enormous stress and change.

## HRO’s embrace these things:

- Know that small things that go wrong are often warning signals of bigger trouble to come.
- Treat near misses and errors as information about the health of their systems and try to learn from them.
- Lastly and a key to my presentation: Understand that if you catch problems before they grow bigger, you have more ways to deal with them.

## TECHNICAL REVIEWS

- The Technical Reviewer is responsible to ensure that the prescribed fire plan meets agency policy and direction.
- Ensure that the Complexity Analysis represents the project.
- Check the prescription parameters to ensure that the project as planned has a reasonable chance of meeting objectives.
- Check to see if the fire behavior predictions and interpretations are appropriate and within an acceptable range given the ignition, holding and contingency  plans.

## HRO’s are used to

- Prevent unwanted outcomes (mindful containment of the unexpected).
- Make an effort to see what the people on the ground see..(Deference to Expertise).
- Permit the proficiency of the organization to come into play-(“Just Culture” *Reason 1997).*
- Make knowledge about the system transparent and widely known.  The more people know about the weaknesses in their (Burn Plan) and how to manage them, the faster they can notice and correct problems in the making.

## Three problems with Planning

- You cannot write procedures to anticipate all the situations and conditions that shape or work.
- Plans presume that consistent high-quality outcomes will be produced  time after time if people repeat patterns of activity that have worked in the past.
- Plans influence perception and reduce the number of things people notice.

## Heightened Mindfulness

- Unexpected events can get us in trouble unless we create a mindful infrastructure that tracks small failures, resists oversimplification, is sensitive to operations, maintains capabilities for resilience, and monitors shifting locations of experience.
- Failing to do a good Tech Review is = to mismanaging the unexpected!

## Expectation

- We “expect” that the burn is doable and will meet our objectives.
- We “expect’ that the fire behavior will be low to moderate complexity.
- We “expect” that we will have a capable organization and resources.
- We “expect” that the prescription will be appropriate under a “narrow” or “wide” spectrum of fuels and weather conditions.

## Small discrepancies found during the Tech Review

- Objectives can’t be achieved.
- Complexity has been over-simplified.
- Resources you thought were available are not and organization is responsive to increasing needs for experience.
- Desired fire behavior and weather preclude resilience.
- Clues that expectations are not viable start to pile up and endanger the project.

## Summary

- What we do is provide a level of HRO’s that is preoccupied with failure.
- Look for lapses that could result in severe consequences especially if several small errors happen to coincide.
- Use near misses for what can be learned and apply that to future projects.
- Have to be the “wary” for liabilities of past successes, including complacency.

## Remember

- Plans guide people to search narrowly for confirmation that the plan is correct.  Disconfirming evidence is avoided, and plans lure you into overlooking a buildup of the unexpected.
- People tend to overestimate the validity of their expectations.
- People actively seek out evidence that confirms their expectations, and avoid evidence that disconfirms them.
- Both of these tendencies become even stronger when people are under pressure.
- As pressure increases, people are more likely to search for confirming information and ignore information that is inconsistent with their expectations.

## Your Job

- Overide these tendencies  and remain alert for faulty expectations.
- Look for limits in the “mental model”, the fire behavior model, the weather models.
- Communicate your findings.

## Just Culture

- An informed culture requires free exchange of information, which requires a culture that is:
- 1.  Just—don’t shoot the messenger
- 2.  Reporting-don’t be afraid of being shot
- Are things happening that I did not plan/expect?
- Have I let someone know?
- Did I learn something that others should know about?

## Just Culture continued

- Learning Culture-learning is continuous
- Have I challenged my assumptions and expectations today?
- Was I lucky or was I good?

## Just Culture continued

- Flexible Culture.  Rules don’t and can’t cover every situation.
- This is not the same thing as a “good rule” misapplied or ignored because it is not convenient or you don’t agree.