# Presentation: 513767

## High Reliability Organizing

- Implementation in Fire Crews

## Agenda

**1. Use Fire Analysis to go to HRO**

**2. Five HRO Processes**

**3. Requisite Culture for Success**

## Fire Management

**Notes:**
Upper left:
Firefighters conduct a burnout at Clear Lake NWR_x000b_during the 2001 Clear Fire. The fire was contained at 4,000 acres. (USFWS) 

Lower left:
Prescribed burn conducted at Stillwater NWR outside of Fallon, Nevada. This photo, taken by FWS firefighter John Wood, wonfirst place in the 2003 Fire Management Today annualphoto contest, Prescribed Fire section. (USFWS) 

Right:
Trees torch within wilderness at Tetlin NWR in Alaska. Wildland fire use in wilderness and other remote areas is often the most appropriate management response.

## Wildland Fire an HRO?

- “High Reliability Organizations
- Nuclear power plants
- Aircraft carriers
-  ***Wildland firefighting crews***

**Notes:**
“HROs such as nuclear power plants, aircraft carriers, and wildland firefighting crews warrant closer attention from managers and organizational leaders because they operate under trying conditions yet experience fewer than their fair share of problems.”
Executive Summary, Managing The Unexpected, 2001 book by Karl E. Weick and Kathleen M. Sutcliffe

Transition question:
	Looking around the room, how many of you think there’s a pretty good chance that one or more of the fire use programs represented here will have an escape that draws some attention from the local, maybe regional, news people?

	How many of you think it could be your fire use program?

## Maybe yours, but not mine!

- How about our prescribed fire programs?Common “surprises” from 28 Escapes and 2 Near Misses 1996-2004 LLC Report

**Notes:**
Fuels and Fire Behavior
	Rate of spread, flame length and resulting spotting were unexpected and a difficult challenge.
	Greater than normal fuel loading due to seasonal variation or a change in land management activities.

Weather
	Changes in moisture increased fine fuels present.
	Unexpected wind events
	Proximity of thunderstorms had an unexpected effect on burning conditions

Comm. and coordination
	Lack of proper notification of changes in conditions
	Lack of agreements with adjacent landowners

Complexity
	Review teams concluded that many burn plans were underrated in complexity.

Chronologies
	Burns either escaped very quickly or several days later during mop up.
	In 12 of 28 escapes it took less than 6 hours or less before escape was declared.
	Test fire was not conducted in a representative location

Image: A prescribed burn at Merritt Island NWR reduces hazardous fuels in the wildland-urban interface. (USFWS) 

## Mindfulness

- To be mindful

- Mindful updating

**Notes:**
To be mindful is to have a rich awareness of discriminatory detail and an enhanced ability to discover and correct errors that could escalate into a crisis.
“Mindful updating is facilitated by five processes that focus on failures, simplifications, operations, resiliencies, and expertise.”

## The past settles its accounts

-   “...the ability to deal with a crisis situation is largely dependent on the structures that have been developed before chaos arrives. *The event can in some ways be considered as an abrupt and brutal audit:* at a moment’s notice, everything that was left unprepared becomes a complex problem, and every weakness comes rushing to the forefront.”**	****	**_Preventing Chaos in a Crisis_, Lagadec, p. 54

**Notes:**
We can only plan and prepare so much before the time of reality arrives.

Transition comment: Let’s put the five HRO processes into the context of our own fire management world, right down to our own fire crew.

## 1. Preoccupation with Failure

- Thinking about our own fire dispatch unit, can we honestly say:
- We regard near misses as a kind of failure that reveals potential danger rather than as evidence of our success and ability to avoid danger

- We treat near misses and errors as information about the health of our system and try to learn from them

**Notes:**
“Since safety cultures are dependent on the knowledge gained from rare incidents, mistakes, near misses, and other free lessons, they need to be structured so that people feel willing to confess their own errors. A reporting culture is about protection of people who report. And it is also about what kinds of reports are trusted...
A culture can not be safe if its reports and reporting relationships are flawed.”

Let me show you an example.

## Triangle of Probability

**Notes:**
Gordon Graham, renown risk management expert, speaking to firefighters in 2002:
“The complex, continually changing dynamics of your job require that workers regularly access their “loaded hard drives” to stay safe and avoid problems up front. Over time, your individual hard drive will load up with the experiences you have in fire. Some of the experiences involve “near misses” in which you almost got hurt or worse. You learned a lesson from this incident, one that you will never forget. Your hard drive is permanently loaded. Who did you share this information with? Probably no one, because of fear of embarrassment or discipline. This is sad. Had you killed yourself or lost a leg, then everyone learns from your tragedy.

Here is a quote from Chaytor Mason (the great Risk Manager of the 60’s and 70’s):
“The only time you learn from the mistakes of another is when they end in tragedy.”
This is unacceptable. Waiting for people to die so we can learn is Un-American.

Based upon the work of Heinrich (Triangle of Probability on this slide),... when a group makes 300 mistakes, 30 will end up in a mishap and one will end up in the “big one.” We all learn from the mistakes of a firefighter when they are seriously injured or killed. This is a good idea. The better idea is to learn when it was just a mishap. The best idea is to learn when it was just a mistake.
Developing a non-punitive near miss reporting system allows others to learn from the greater volume of the mistakes of, optimally, all firefighters across the nation.”

## Triangle of Probability

**Notes:**
Well we have SAFENET and SAFECOM don’t we? A good step in the right direction, but...

Dick Mangan, president of IAWF speaking at the International Safety Summit 2006:
“Over the years we have averaged about 20 seriously or fatally injured wildland firefighters each year.”

How many learning opportunities should we have had available to us EVERY year?

## 2. Reluctance to Simplify

- Thinking about our fire crew, can we say:
- People around here take nothing for granted
- People are encouraged to express different points of view

**Notes:**
Considering the second HRO process.

## 3. Sensitivity to Operations

- During an average day, people come into enough contact with each other to build a clear picture of the situation.
- People are familiar with operations beyond one’s own job.

## 4. Commitment to Resilience

- There is a concern with building people’s competence and response repertoires.
- People have a number of informal contacts that they sometimes use to solve problems.

## 5. Deference to Expertise

- If something out of the ordinary happens, people know who has the expertise to respond
- People in this organization value expertise and experience over hierarchical rank

## Toward a “Mindful Culture”

- A healthy safety culture consciously  creates mindfulness.

- Strive for an “informed culture”– a culture that creates and sustains intelligent wariness. – James Reason

- Informed cultures result from four _co-existing_ subcultures:

**Notes:**
Human factors researcher James Reason has developed a detailed and persuasive argument that a safety culture is an informed culture.

“The best way to maintain these states of wariness is to collect and disseminate information about incidents, near misses, and the state of the system’s vital signs. The problem is that candid reporting of errors takes trust and trustworthiness. Both are hard to develop, easy to destroy, and hard to institutionalize.”
Weick & Sutcliffe, MTU pp. 129

## Four Subcultures

**Reporting culture**** **
**Just culture**
**Flexible culture**
**Learning culture**

**Notes:**
Reporting culture: What gets reported when people make errors or experience near misses? 
Just culture: How do people apportion blame when something goes wrong?
Flexible culture: How readily can people adapt to sudden and radical increments in pressure, pacing, and intensity?
Learning culture: How adequately can people convert the lessons that they have learned into reconfigurations of assumptions, frameworks, and action for all dispatch units?

## Dependency Diagram

**First**

- Second

- Third

- Fourth

**Just****Culture**
- Trust
- Clarity

- ReportingCulture
- ReportingRelationships

- FlexibleCulture
- Adaptable

- LearningCulture

**Notes:**
“An organization is defined by how it handles blame and punishment, and that in turn can affect what gets reported in the first place. A just culture is described as “an atmosphere of trust in which people are encouraged, even rewarded, for providing essential safety-related information ---but in which they are clear about where the line is drawn between acceptable and unacceptable behavior.”
“That line is CRUCIAL because it separates unacceptable behavior that deserves disciplinary action from behavior for which punishment is not appropriate and the potential for learning is considerable.
Reason reports that when this line is clear, only about 10% of the unsafe acts fall into the unacceptable category...If people are unclear about what constitutes grounds for punishment, if people feel ashamed to admit errors, and if management deals with errors in an inconsistent manner, then that 90% will be concealed.
As a result, the system will be seriously deficient in understanding how vulnerable it really is.”
Weick & Sutcliffe, MTU pp. 131-132

## Toward a Mindful Culture

**First**

- Second

- Third

- Fourth

- JustCulture
- Trust
- Clarity

- ReportingCulture
- ReportingRelationships

- FlexibleCulture
- Adaptable

**Learning****Culture**

**Notes:**
“If timely, candid information generated by knowledgeable people is available and disseminated, an informed culture becomes a learning culture.”
Weick & Sutcliffe, MTU pp. 131-132

“When you think about mindful culture as a means to manage the unexpected, keep the following picture of culture in front of you.
Culture is about the assumptions that influence the people who manage the unexpected. Culture can hold large systems together. Culture is unspoken, implicit, taken for granted. You feel culture when what you do feels appropriate or inappropriate. You feel the unexpected when something surprises you. Culture produces simultaneous centralization-decentralization by binding people to a small set of core values and allowing them discretion over everything else.”
Weick & Sutcliffe, MTU pp. 138-139

## Pay Attention Differently

- You **STOP** concentrating on some things.
- You **START** concentrating on other things.

**  ****To Be Mindful****	****Is**** to “See more Clearly” ****	****Not**** to Think Harder and Longer**

**Notes:**
Some firefighters will say, “This sounds a lot like common sense, just pay closer attention to what’s going on!”

You STOP concentrating on those things that confirm your hunches, are pleasant, feel certain, seem factual, are explicit, and that others agree on!

You START concentrating on things that disconfirm, are unpleasant, feel uncertain, seem possible, are implicit, and are contested!

HRO eventually creates different “Scanning Patterns.” Quickly and continuously “Scanning” more than a “Thinking” thing.

## “See more clearly”

- See where your model didn’t work, or see indicators you missed that signaled expectations weren’t being filled **(failure)**

- Strip away labels, stereotypes that conceal differences among details **(simplification)**

- Focus on what is happening here and now **(operations)**

- See new uses for old resources through improvisation and making do **(resilience)**

- Discover people who understand a situation better than you do and defer to them **(expertise)**

**Notes:**
How seeing more clearly can be expressed in light of the five HRO processes.
See where your model didn’t work, or see indicators you missed that signaled expectations weren’t being filled (failure)
Strip away labels, stereotypes that conceal differences among details (simplification)
Focus on what is happening here and now (operations)
See new uses for old resources through improvisation and making do (resilience)
Discover people who understand a situation better than you do and defer to them (expertise)

## Plans and Their Drawbacks

- Plans influence what people see

- Plans can limit our view of our capabilities

- Plans focus attention on what we expect

**Notes:**
Plans are a good thing, a very necessary thing, but we need to be aware how they can also get us into trouble.

Plans influence what people see, what they take for granted, what they choose to ignore, and how easy it is for them to spot small problems that are growing.

Plans focus attention on what we expect and what we can do, which leaves out many potentially crucial details. 

A heavy investment in plans can limit our view of our capabilities to those we now have and expect to use.

## Preoccupation with Failures

- All Failures
- Especially The Small Ones

**Notes:**
HROs are preoccupied with all failures, especially small ones.
Small things that go wrong are often early warning signals of deepening trouble and give insight into the health of the whole system.

If you catch problems before they grow bigger, you have more possible ways to deal with them.

But, we have a tendency to ignore or overlook our failures (which suggest we ARE NOT competent) and focus on our successes (which suggest we ARE competent).

## Learning by Failure – Hard

- Learning moments are short-lived
- Don’t wait
- Do it the right way

**Notes:**
“HROs learn from their mistakes as a result of swift processing. Most other organizations don’t.
HROs recognize the human tendency that when people fail, they tend to be candid about what happened for a short period of time, and then they get their stories straight in ways that justify their actions and protect their reputations. And when official reports get straightened out, delayed, (redacted, and edited for political correctness), learning stops.”
p. 57-58, MTU

## James Reason, 2006

**Notes:**
James Reason has been studying human error and models of error management for decades.
February 13, 2006 he spoke in Helsinki at an International Human Factors Conference. These are his slides.

## The Person Model

**Notes:**
The Person Approach focuses on the errors of individuals, blaming them for forgetfulness, inattention, or moral weakness 
	Remedies are directed at reducing unwanted variability in human behavior and usually include: writing another or adding to existing procedures, disciplinary measures, threat of litigation, retraining, naming, blaming, and shaming, even assuming that bad things happen to bad people.

## The Legal Model

## The System Model

**Notes:**
The System Approach concentrates on the conditions under which individuals work and tries to build defenses to avert errors or mitigate their effects
	Humans are fallible and errors are to be expected, consequences rather than causes, having their origins in upstream systemic factors. We can not change the human condition, but we can change the conditions under which humans work using system defenses of barriers and safeguards. When an adverse event occurs, the important issue is not who blundered, but how and why the organization’s defenses failed. (Swiss Cheese Model)

## Satisfying with “Justice Fruit”

**Notes:**
Someone has to be held accountable.
“Blaming individuals is emotionally more satisfying than targeting institutions.” James Reason

## Upward and Outward

**Notes:**
Finger-pointing that goes in all directions is common in justification.
The upward delegation of blame comes easier than taking responsibility too.
Society at large external influences: political, economic, etc.

## A Balanced Approach?

**Notes:**
James Reason wrote several pieces about Just Culture over several decades that are being used today to get organizations to take a look at themselves instead of staying on the personal and legal approaches to managing error.
In 2006 James Reason now says that while some are still focused on the individual, this pendulum has already begun to swing too far out toward remote factors in some organization’s error management efforts (i.e. blaming the entire air transportation system, the incorrect running of the economy, the post-cold war policy environment, etc.).

## Use A Balanced Approach?

- Person Approach?
- Legal Approach?
- System Approach?

- Learning Approach

**Notes:**
We need it, but does a “Balanced Approach” exists?

The Learning Approach does not attempt to place blame on either the individual or the organization, but looks at everything before, during and after an event as an opportunity to learn and adjust.
	HRO’s expect errors to occur and train their workforce to recognize them early in their development and to recover quickly from them. They continually rehearse familiar scenarios of failure and strive hard to image novel ones. Instead of only making local repairs, they look for enterprise-wide knowledge transfer and reform.

## Learning requires some preconditions:

psychological safety

learning orientation 

efficacy

- psychological safety
- learning orientation
- efficacy

***Learning Ground Rules***

**Notes:**
Learning requires some preconditions:
 psychological safety (tolerance for mistakes of commission)
 learning orientation (intolerance for mistakes of omission)
efficacy (belief that together we can handle what comes up)

## 2. Reluctance to Simplify

- Our Expectations

**Notes:**
Our expectations help us simplify our world and steer us away from disconfirming evidence. 

Basic idea is:
we see what we expect to see
we see what we have labels to see
we see what we have skills to manage

We need to create more varied and differentiated expectations in order to better understand what we face.

Our goal is “requisite variety,” loaded in our hard drives, or many, many slides in our slide trays.

## 3. Operations-Sensitive Leadership

- Encourage others to speak up
- Check for comprehension
- “Over Learn” new routines

**Notes:**
Encourage others to speak up and ask questions (knowledge lies between heads)..
Check for comprehension; acknowledge what you hear.
Be aware of how you react to pressure; tell others.
Verbalize your plans and “Over Learn” new routines.

## 4. Commitment to Resilience

- A combination:
- Keeping errors small and
- Improvising workarounds that keep the system functioning
- Build dynamic thinking skills
- Develop creativity
- Value variability

**Notes:**
Trouble starts small and is signaled by weak symptoms that are easy to miss, especially when expectations are strong and mindfulness is weak. Small moments of inattention and misperception can escalate swiftly into unmanageable trouble.

Surprises are inevitable. And with the unexpected surprise comes the necessity to improvise, make do with the hand you are dealt, adapt, think on your feet, contain and come back from unexpected events.

Resilience demands deep knowledge of the technology, the system, one’s coworkers, one’s self, and the raw materials you have to work with. HRO’s put a premium on experts; personnel with deep experience, skills of recombination, and training.

Other organizations try to minimize variability. HRO’s see variability as possible their greatest asset. 

## 5. Defer to Expertise

- HROs shift decisions toward expertise and experience.

**Notes:**
HROs shift decisions away from formal authority toward expertise and experience.

HROs have flexible decision-making structures; their networks do not have a fixed central player who can mistakenly assume that she/he knows everything.

Decision making migrates to experts at all levels of the hierarchy during high tempo times.

## Sensemaking vs Decisionmaking

- “If I make a decision it is a possession; I take pride in it; I tend to defend it and not to listen to those who question it.
-  If I make sense, then this is more dynamic and I listen and I can change it.
- A decision is something you polish. Sensemaking is a direction for the next period.”
- --Paul Gleason

## STICC – Explain Yourself

_**S**_**ituation**
_**T**_**ask**
_**I**_**ntent**
_**C**_**oncern**
_**C**_**alibrate**

**Notes:**
Leaders, when you believe you have made sense of a situation communicate in a systematic way. Practice doing it this way all of the time.

Situation:  Here’s what I think we face
Task:  Here’s what I think we should do and the direction we should take for now
Intent:  Here’s why
Concern:  Here’s what we need to watch
Calibrate:  Now talk to me

## Continually Ask Yourself

- Scanning questions:
- Can I see weak signals of failure and make sense of them?
- How many different slides do I have that apply to this situation?
- Am I aware of the unfolding situation?
- Do I have the skills to make do?
- Who knows how to do what?

**Notes:**
Everyone should continually ask themselves:
Can I see weak signals of failure and make sense of them? (Small Failures, how healthy is the system really?).
How many different slides do I have that apply to this situation? (Simplification).
Am I aware of the unfolding situation? (Operations).
Do I have the skills to make do? (Resilience).
Who knows how to do what? (Expertise).

##  Five Continuous Processes

- deference

- preoccupation

- reluctance

- sensitivity

- commitment

- Manage the Unexpected

**Mindful Updating**

**Notes:**
Preoccupation with failures rather than successes
Reluctance to simplify interpretations
Sensitivity to operations
Commitment to resilience
Deference to expertise, as exhibited by encouragement of a fluid decision-making system

We attribute the success of HROs in managing the unexpected to their determined efforts to act mindfully. By this we mean that they organize themselves in such a way that they are better able to notice the unexpected in the making and halt its development. If they have difficulty halting the development of the unexpected, they focus on containing it. And if some of the unexpected breaks through the containment, they focus on resilience and swift restoration of system functioning.

## Five Processes

**1. Preoccupation with failure**

**2. Reluctance to simplify**

**3. Sensitivity to operations**

**4. Commitment to resilience**

**5. Deference to expertise**

**Notes:**
What are you good at?
Are you consistently better at anticipation (the first three processes of mindfulness) than containment (the last two processes)? You would expect that to occur in rational organizations, obsessed with planning.

And because the value of building resilience and developing flexible decision processes is often underestimated in most organizations, it is natural to expect the latter two processes to be your poorest. Are they?

If not, you’re on your way to being a more mindful organization.  Rank order the five processes according to what you are best and worst at doing. Is your culture what is holding that rank ordering in place?

## Cultural Progression to HRO

**Just**

**Reporting**

**Flexible**

**Learning**

**Notes:**
Simply stated, culture is the way we do things around here. 
“Its not just what people think, as important as that is, but more importantly about how people feel. You need people to absorb the lessons of mindfulness at an emotional level so they will express approval when others hold certain beliefs and act in certain ways.
For example, people need to feel strongly that its good to speak up when they make a mistake, good to spot flawed assumptions, good to good to focus on a persistent operational anomaly. They need to expect praise when they do them, and they need to offer praise when they spot someone else doing them.
Likewise, you need to attach disapproval to people believing and acting in ways that undermine mindfulness.
For example, people need to agree among themselves and feel strongly that it’s bad to refrain from asking for help, bad to let success go to their heads, bad to ignore lower-ranking experts.
They need to express key values by making it clear what is disapproved as much as by praising what is approved.”
pp. 118-119, MTU

## Mindfulness Defined

- “By mindfulness we mean the combination of

- Ongoing scrutiny of existing expectations,

- Continuous refinement and differentiation of expectations based on newer experiences,

- Willingness and capability to invent new expectations that make sense of unprecedented events,

- A more nuanced appreciation of context and ways to deal with it,

- And identification of new dimensions of context that improve foresight and current functioning.”

**Notes:**
“That is a mouthful. But sometimes it takes complexity to define a complex phenomenon... a complex set of ideas to understand just what HROs are doing and why it works.”
Weick & Sutcliffe, MTU pp. 42

People who act mindfully notice and pursue that rich, neglected remainder of information that mindless actors leave unnoticed and untouched. Mindful people can hold complex projects together because they understand what is happening. That is what HROs can teach you.

## Where we are going

**Notes:**
We are living in very interesting times.
The Mine Fire, San Diego County, California burnedthrough the wildland urban interface in 2003. (USFWS) 

More than ever before, we need to learn quickly. Successful units repeatedly use these techniques to ensure faster learning, more alert sensing and better relationships that create mindfulness. 

## Information to Knowledge

*Information to Knowledge*

**Informed Culture**

- Timely

- Available

- Candid

- Disseminated

**Learning Culture**

**Notes:**
“If timely, candid information generated by knowledgeable people is available and disseminated, an informed culture becomes a learning culture.” HRO prospers in a sustained learning culture.

## Agenda

**1. Use Fire Analysis to go to HRO**

**2. Five HRO Processes**

**3. Requisite Culture for Success**

## Commitment – Pick Two

**1. Preoccupation with failure**

**2. Reluctance to simplify**

**3. Sensitivity to operations**

**4. Commitment to resilience**

**5. Deference to expertise**

**Notes:**
What do you think your two weakest HRO areas are?

Write them on something that you can put on your desk back home by the phone.
After a week, ask yourself what you have started doing. If not, ask why not?
Are there competing commitments?

## HRO Support at LLC

- _[www.wildfirelessons.net](http://www.wildfirelessons.net/)__ _

**Notes:**
There are 9 HRO audits that you can run with your organization when you get back to your unit. There is also advice from K&K on how to use the audits on the Lessons Learned Center’s HRO Website page.

Look for the next regional MTU/HRO Workshop in your region to be announced by the LLC.

**Notes:**
Formal teams accomplish much of their work here as well as informal groups.

Why not crew bosses, sawyers and swampers, burn out operations specialists, engine crews, dispatch units, etc.

## HRO Support at MFC

- _[www.myfirecommunity.net](http://www.myfirecommunity.net/)__ _

**Notes:**
There’s already an area for HRO groups to share ideas and discuss real issues.

## Questions? Contact Us

- Paula Nasiatka, LLC Manager
- (520) 799-8760, _[pnasiatka@fs.fed.us](mailto:pnasiatka@fs.fed.us)__ _
- David Christenson, LLC Asst. Mgr.
- (520) 799-8761, _[dchristenson@fs.fed.us](mailto:dchristenson@fs.fed.us)__ _
- Brenna MacDowell, LLC Editorial Asst.
- (520) 799-8763, _[bmacdowell@fs.fed.us](mailto:bmacdowell@fs.fed.us)__ _

**Notes:**
There are people at the LLC who can help your unit be successful with HRO.