United States

Department

of Agriculture

Forest Service

Rocky Mountain

Research Station

General Technical

Report RMRS-GTR-137

October 2004

Managing

the Unexpected

in Prescribed Fire

and Fire Use Operations

A Workshop

 on the High Reliability

Organization

As part of

“Organizational Learning”

the workshop’s primary goal:

To explore and possibly adopt

the concepts of “High Reliability Organizing”

for “Managing the Unexpected” to help us

better implement our wildland fire use and

prescribed fire programs.

Co-Chaired by:

• USDA Forest Service

• USDI National Park Service

• Rocky Mountain Research Station

• Wildland Fire Lessons

Learned Center

• Missoula Fire Sciences Laboratory

• National Wildfire Coordinating Group

Social Science Task Group

• The Nature Conservancy

• U.S. Fish and Wildlife Service

Santa Fe, New Mexico

May 10-13, 2004
Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization

Abstract

How do we organize for high performance in a setting where the potential for error and disaster

can be overwhelming? In doing so, how can we best apply the High Reliability Organizing

concepts into the prescribed fire and fire use arenas? And, to successfully achieve these

outcomes, how can we personally and institutionally overcome our immunity to change?

This report summarizes how these questions—and many others—were addressed through the

activities, discussions, and lessons learned during the four-day Managing the Unexpected

Workshop held May 10-13 2004, in Santa Fe, New Mexico. The report documents and examines

the day-to-day workshop chronology from its opening keynote address and “Managing the

Unexpected” presentation, through the all-day Staff Ride to the 2000 Cerro Grande Prescribed

Fire site, the Staff Ride’s Integration Phase, and the final day’s thoughtprovoking and

challenging “Immunity to Change” exercise.

Overall workshop intent was to introduce the latest social science to the prescribed fire and fire

use management community.

Noted organizational psychologists Dr. Karl E. Weick, the Rensis Likert Distinguished University

Professor of Organizational Behavior and Psychology, and Dr. Kathleen Sutcliffe, of the University

of Michigan Business School, were the workshop’s featured presenters. Authors of Managing the

Unexpected – Assuring High Performance in an Age of Complexity, they participated in the

entire four-day workshop “clarifying ideas, answering questions, and learning,” notes Dr. Weick.

In addition, the Harvard University Graduate School’s organizational psychologists Dr. Robert

Kegan, William and Miriam Meehan Professor of Adult Learning and Professional Development,

and Dr. Lisa Lahey, Research Director of the Change Leadership Group, were also featured

presenters. Authors of The Real Reason People Won’t Change, they introduced workshop

participants to their psychologically dynamic Immunity to Change exercise. Twenty workshop

participants participated with Kegan and Lahey in a three-month “coaching process” followup.

The workshop was hosted by: The USDA Forest Service; USDI National Park Service; Rocky

Mountain Research Station; Wildland Fire Lessons Learned Center; Missoula Fire Sciences

Laboratory; National Wildfire Coordinating Group’s Social Science Task Group; The Nature

Conservancy; U.S. Fish and Wildlife Service.

Key Words

High Reliability Organization, Mindfulness, Learning Organization, Staff Ride, Sensemaking,

Immunity to Change, prescribed fire and fire use.
Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization

Managing the Unexpected in Prescribed Fire Use Operations

A Workshop on the High Reliability Organization

Santa Fe, New Mexico May 10-13, 2004

Technical Writer-Editor

Paul Keller

Contributing Authors

Dr. Karl E. Weick

Rensis Likert Distinguished University Professor

of Organizational Behavior and Psychology

University of Michigan Business School

Dr. Kathleen Sutcliffe

University of Michigan Business School

Dr. Jim Saveland

Assistant Director for Research Rocky Mountain Research Station

Dr. Lisa Lahey

Research Director of the Change Leadership Group

Harvard University Graduate School

Dave Thomas

Regional Fuels Specialist

Intermountain Region, USDA Forest Service

Paula Nasiatka

Manager Wildland Fire Lessons Learned Center
Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization

Contents

Acknowledgments ....................................................................................... 1

I What Happened? Why? What Happens Next?................................................. 2

Workshop Objectives ............................................................................................................ 2

II Putting This Workshop into Perspective .............................................................. 4

A Brief Historical Context....................................................................................................... 6

III Workshop’s Keynote Address

Why do we need this kind of thinking

in our fire use and fire suppression organizations?............................................................. 8

Time to develop an organizational framework that can adapt

and evolve without large losses as a prerequisite .................................................... 10

Complexity is increasing – today’s wildland fire situation is

very different from our past institutional fire use experience ................................... 11

This workshop – and you – can help us become a

High Reliability Organization ........................................................................................ 13

IV Day One – Managing the Unexpected

How do you organize for high performance

in a setting where the potential for error and disaster

can be overwhelming? ...................................................................................................... 14

The Five Central Processes That Produce Mindfulness ............................................. 14

How to Work Toward a Mindful Culture...................................................................... 19

A Mindful Infrastructure for High Reliability ................................................................. 22

“To avert disasters of biblical proportion,

we need to become organizations that adapt

and evolve in anticipation of catastrophes

rather than as a result of catastrophes.”

Tim Sexton, National Fire Use Program Manager

USDA Forest Service

Workshop’s Keynote Speaker
Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization

V Day Two – Cerro Grande Staff Ride

How Can We Apply the High Reliability Organizing Concepts

to the Cerro Grande Prescribed Fire? ............................................................................... 24

VI Day Three – Staff Ride Integration Phase

and Facilitated Group Discussions

A. Staff Ride Integration Phase

1. Praise and Empathy for Cerro Grande Prescribed Fire Crew .............................. 36

2. Need to Change Investigation Process and Reports ........................................... 38

3. Constructive Criticism on this Prescribed Fire......................................................... 40

4. Paul Gleason’s Influence: Positive or Negative? ................................................... 41

5. Positives from This Prescribed Fire ............................................................................ 43

6. Criticisms of the National Prescribed Fire Program ............................................... 43

7. Feedback on the 2000 Santa Fe Dispatch Organization ..................................... 45

8. Lack of Resources ..................................................................................................... 46

9. Stakeholders .............................................................................................................. 46

10. The Staff Ride as Learning Tool .............................................................................. 47

B. Facilitated Group Discussions......................................................................................... 48

VII Weick and Sutcliffe’s Follow-up to Workshop Participants

1. ‘Preoccupation with Failure’ – You Missed a Key Point ........................................ 54

2. ‘A Reluctance to Simplify’ – You Need Practice................................................... 56

3. ‘A Sensitivity to Operations’ – Not as Easy as It Looks ........................................... 58

4. ‘A Commitment to Resilience’ – Your AARs Might Be Promoting

The Wrong Thing ..................................................................................................... 59

5. ‘A Deference to Expertise’ – ‘Expertise’ Doesn’t

Equate to Experience ............................................................................................ 61

Karl Weick’s Key Principles to Emphasize

1. You Don’t Need More Data .............................................................................. 62

2. Small Stuff Makes All the Difference ................................................................. 62

3. Reliability is Not Bankable .................................................................................. 63

“A Learning Organization must be able

To create, acquire, interpret, and

obtain knowledge. It must also

purposely modify its behavior to

reflect new knowledge

and insights.”

Paula Nasiatka, Manager

Wildland Fire Lessons Learned Center

Workshop Moderator
Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization

VIII Day Four

Immunities to Change: A Facilitated ‘How to’ Commitment Exercise

Presented by Robert Kegan and Lisa Lahey .................................................................... 64

How to: Uncover Your Inexplicable Resistance to Change

and Your Subconscious Goals ........................................................................................... 66

IX Conclusion – We Have Lit a Match and Started a Fire .................................. 69

X Steering Committee Members........................................................................... 73

“We cannot guarantee that attempting to develop a High Reliability

Organization framework for our prescribed fire and fire use operations

will prevent escapes. That would be unrealistic. But by working with this

key learning organization concept, we are exhibiting leadership in the

prescribed fire arena—hopefully, becoming even more assured that

we are doing everything possible to lessen the chance of serious

escapes, and to increase the chances of replicating our successes.

Through this workshop, our prescribed fire managers will therefore be

taking the initial steps in becoming experts at organizational learning

and managing the unexpected.”

Dave Thomas, Chair

Managing the Unexpected Workshop

Tom Iraci Photo USDA Forest Service

Managing the Unexpected Workshop Steering Committee members meet with the Staff

Ride presenters and facilitated group discussion leaders.
Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization 1

Acknowledgements

The Managing the Unexpected Workshop could not have occurred without the hard work and

personal dedication of Dick and Barbara Mangan, Blackbull Wildfire Services, Missoula,

Montana.

The workshop’s success is due in large part to the contributions of Karl Weick and Kathleen

Sutcliffe. We are indebted to their sincere efforts to help us better understand and apply their

High Reliability Organizing ideas and concepts. Likewise, we are grateful to Robert Kegan

and Lisa Lahey’s commitment to helping us implement these concepts.

The Steering Committee also thanks Mark Beighley, Jerry Williams, and Tom Harbour,

Washington Office Fire and Aviation Management, USDA Forest Service, for their strong

initial support—both financial and personal—in using the “High Reliability Organization”

and “Learning Organization” concepts to improve our prescribed fire and wildland fire use

operations.

The workshop also benefited from the strong support of Dick Bahr, Fire Use Specialist, Fire

Program Center, National Park Service; and Mike Hilbruner, National Program Leader for

Fire Systems Research, USDA Forest Service.

June Genf, Support Services, Forest Service Intermountain Regional Office, was immensely

helpful in supporting the workshop’s logistical and contracting tasks.

We also truly appreciate the Bandelier National Monument employees’ hospitality in

allowing us to return to Cerro Grande for the Staff Ride. Finally, we would like to thank all

the Managing the Unexpected Workshop participants, facilitators, and speakers from all the

agencies—both external and internal—for their personal dedication to the workshop’s goals

and objectives. The end result is more lands properly managed through the beneficial and safe

use of fire.

KICK OFF – Paula Nasiatka, Manager of the Wildland Fire Lessons Learned Center,

introduces and launches the four-day workshop at its Monday morning opening.
2 Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization

“The people who operate and manage High Reliability Organizations assume that

each day will be a bad day and act accordingly. But this is not an easy state to

sustain, particularly when the thing about which one is uneasy has either not

happened, or has happened a long time ago

and perhaps to another organization.”

From Managing the Unexpected

by Karl E. Weick and Kathleen M. Sutcliffe

I What Happened? Why? What Happens Next?

Mindfulness . . .

Paying attention—individually and

organizationally—in different ways . . .

Learning how to struggle for a new

alertness . . .

Our preoccupation with failure . . . How the

architecture of simplicity can get us into trouble

. . . Rather than relying on “experts,” letting

decisions “migrate” to those with the proper expertise to make them . . . Discovering how

to anticipate and prepare for surprises by

learning to develop new skills of resilience . . .

These are some of the concepts, tools, and

skills that 85 people immersed themselves in

during the week-long Managing the

Unexpected Workshop. These participants—

representing various local, state, and federal

agencies from all levels of their

organizations—are directly involved in

planning, implementing and learning from

prescribed fire and fire use operations.

Overriding intent of this week-long event:

• To understand and adopt these High

Reliability Organizing concepts, tools,

and skills.

• To take these concepts, tools, and skills

back home to refine, share and apply in

participants’ own work and organizations.

Workshop Objectives

1. Explain the basic concepts of a

High Reliability Organization.

2. Compare High Reliability

Organizations with participants’

own organizations.

3. Participate in the Cerro Grande

Staff Ride.

4. Participate in facilitated group

discussions to work out uses of High

Reliability Organizations in fire use

operations at the individual and

organizational levels.

5. Participate in an “Immunity to

Change” exercise to increase the

chance of High Reliability

Organization concepts being

adopted in the field.

Workshop participants came from as far away

as Australia and New Zealand.
Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization 3

Organizations represented at the workshop

included: U.S. Forest Service; National Park

Service; Bureau of Indian Affairs; Bureau of

Land Management; Maine Forest Service;

Los Angeles Fire Department; Alberta

Sustainable Resource Development Forest

Protection Division; Parks and Wildlife

Service, Hobart, Tasmania; City of Boulder

Fire and Rescue; North Lake Tahoe Fire

Protection District.

Central Focus: Staff Ride

Workshop participants discovered and

applied key High Reliability Organizing

principles. In doing so, a central focus of the

workshop was a “Staff Ride” field visit to the

nearby Cerro Grande Prescribed Fire site.

This was the May 2000 prescribed fire that

escaped and eventually burned into Los

Alamos, New Mexico and its surrounding

communities.

Revisiting this prescribed fire event with its

key participants—who honored the workshop

with their attendance and participation—

enabled unique hands-on insights into applying High Reliability Organizing concepts to

participants’ required work expectations and

professional responsibilities on the landscape.

“The Staff Ride was the key to this week,”

said Dick Bahr, Fire Use Specialist with the

National Park Service’s Fire Program Center.

“The Staff Ride got everybody’s feet on the

ground and simultaneously brought Karl

Weick and Kathleen Sutcliffe’s High

Reliability Organizing concepts to life.”

Ensuring the Worshop’s Learning and

Insights Make It Back Home—Make

a Difference to Your Organization

On the workshop’s last day, participants were

given a set of processes to facilitate a method

of ensuring that what they’d learned would

return home with them—that they would be

able to apply these High Reliability

Organizing concepts into their own work

systems.

To help propel this effort, organizational

psychologists Robert Kegan and Lisa Lahey,

the last day’s featured presenters, walked the

workshop participants through their

comprehensive “Immunities to Change”

exercise.

“It seems that at even the best of conferences

people get very pumped up. But they don’t

have that same energy level when they return

home,” Lisa Lahey explained. “We want to

increase the likelihood that you can find a way

to take this energy back with you.”

Underlying

workshop theme is

to help ensure that

concepts and

knowledge absorbed

this week make it

back to home

units—to help

stimulate personal

and organizational

change.

Photos by Tom Iraci USDA Forest Service
4 Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization

In 1969, Dr. Karl E. Weick’s book The Social

Psychology of Organizing “turned

organizational psychology on its head by

praising the advantages of chaos,

demonstrating the pitfalls of planning, and

celebrating the rewards of ‘sensemaking,’”

pointed out The Harvard Business Review in

its recent article Sense and Reliability: A

Conversation with Celebrated Psychologist

Karl E. Weick.

Dr. Weick expanded on these insights in his

1995 book Sensemaking in Organizations.

II Putting This Workshop Into Perspective

Karl Weick, internationally recognized expert on High Reliability Organizations,

explains to the workshop participants that these are organizations who operate under

very trying conditions—performing, sometimes on a daily basis, high-risk

operations—and yet manage to have fewer than their share of accidents.

Tom Iraci Photo USDA Forest Service
Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization 5

In 2001, Weick, the Rensis Likert

Distinguished University Professor of

Organizational Behavior and Psychology at

the University of Michigan Business School,

together with University of Michigan

colleague Dr. Kathleen Sutcliffe, co-wrote the

acclaimed Managing the Unexpected –

Assuring High Performance in an Age of

Complexity.

In this book, the two distinguished

researchers and thought-leaders on

organizational concepts and strategies,

examine organizations that must manage

unexpected threats and therefore can’t afford

to make mistakes. These include flight deck

crews on aircraft carriers, nuclear

power-generation and chemical production

plants, air traffic control systems, hospital

Tom Iraci Photo USDA Forest Service

emergency departments, and the entire wildland

and prescribed fire community.

After years of researching excellence in

responding to crises in these inherently

complex and potentially dangerous

organizational settings, these two national

experts on organizations, strategies, and

management are heralded for helping to

develop the concept of “High Reliability

Organizations.”

Weick and Sutcliffe’s work and insights served

as the underlying theme of the Managing the

Unexpected Workshop. In attendance

throughout the week, they were featured the

first day when they launched the workshop by

presenting and discussing the processes and

principles of High Reliability Organizing.

“As a manager and agency administrator,” said one participant at the end of the fourth day, “I found

this workshop to be practical, ‘turf-free,’ open, and very productive.”
6 Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization

A Brief Historical Context

That first morning, Jim Saveland, Assistant Director for Research, Rocky Mountain

Research Station, introduced Weick and Sutcliffe to the workshop audience. He

recognized their significance to the wildland and prescribed fire community by

placing them in historical perspective with this chart.

Ecological Ecological

Science Science

1910s Frederick

Clements

“Theory of

Succession”

1930s

1960s

Today

Management Management

Science Science

Fire

Management Management

Frederick Taylor

“Scientific

Management”

Coert duBois

“Systemic Protection of

California Forests”

Arthur Tansley

Coined

“Ecosystem”

Herbert Stoddard

“The Bobwhite

Quail”

Kurt Lewin

“Action Research”

10 a.m. Policy

Aldo Leopold

Elers Koch

Eugene Odum

“Fundamentals

of Ecology”

Douglas McGregor

“Theory X and Y”

“The Human Side of

Enterprise”

Wilderness Act

Wildland Fire Use

Disturbance

and Landscape

Ecology

Karl Weick,

Kathleen Sutcliffe

Robert Kegan,

Lisa Lahey

Chris Argyris,

Daniel Kahneman

Sustainable/Healthy

Forests and Rangelands

Firefighter Safety

Controlling Costs

Prescribed Fire Escapes
Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization 7

Beware: There’s Danger in Simplifying Our Complexities

“Weick and Sutcliffe note that High Reliability Organizations are“‘reluctant to simplify the

complexities that define their environment.’

For most of us, our Land and Resource Management Plans are cumbersome, complex documents that

seem only indirectly related to safety, cost, and risk. These plans can seem abstract or obtuse in

relation to the operational dimensions of wildland fire management.

Although the Forest Service typically spends about $600 million per year fielding a fire suppression

force and another $500 million per year suppressing unwanted fires, we often lack enthusiasm for the

large-scale Land and Resource Management Plan revisions or amendments that might help reduce the

potential for destructive, high-intensity fires.”1

Jerry Williams, Director, Fire and Aviation Management

USDA Forest Service

Be Glad When You’re Having A Bad Day

“. . . How many times have we seen executives and administrators attempt to manage the unexpected

after-the-fact by blaming it on someone—usually someone else. Karl E. Weick and Kathleen M.

Sutcliffe offer insight into this problem.

But we shouldn’t expect easy answers because their goal is to help us learn to cope in realworld

organizations and to work together to improve them. For that, we must abandon the search for quick

fixes and embrace the reality of living in complex, adaptive systems and organizations.

. . . Weick and Sutcliffe stress that sometimes you can’t wrap complex subjects into neat, tidy packages

too often seen in the business and management literature. . . . Even the terms they use are unexpected

to those who are steeped in win-win or quick-fix reactive management cultures. Weick and Sutcliffe

advise us to, among other things:

• Cultivate humility.

• Be glad when you’re having a bad day.

• Create an error-friendly learning culture.

• Develop skeptics.

• Be suspicious of good news.

• Seek out bad news.

• Treat all unexpected events as information—share this information widely.”2

Dave Iverson, Regional Economist for Intermountain Region

USDA Forest Service

1 Williams, J. 2002. Next Steps in Wildland Fire Management. Fire Management Today. 62 (4): 35.

2 Iverson, D. 2002. Book Review: Managing the Unexpected. Fire Management Today. 62 (4): 36-37.
8 Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization

Events like the May 2000

Cerro Grande prescribed

fire escape.

Organizationally, we have

a pretty good history of

learning from our—“great

magnitude” mishaps. In

fact, in almost all cases,

our significant organizational and technological

improvements have

resulted from a nationally

significant precursor

event: a tragedy wildfire

or a calamitous escaped

Every year, our initial attack and fire use

program success rates hover around 98%.

Thus, only about 2% of our initial attacks

escape to become large wildfires.

Furthermore, less than 2% of our prescribed

burns escape to become wildland fires.

That’s pretty good isn’t it?

Unfortunately, the answer—when one

considers the magnitude of the

consequences and outcomes of these albeit

small fraction of escapes—is:

Perhaps not.

We need to seek to eliminate these events

that result in the loss of life—such as the

recent South Canyon, Thirty-Mile, and

Cramer wildfires. And we need to seek to

eliminate those events that also

overshadow—economically, socially, and

politically—our entire national programs.

III Workshop’s Keynote Address

Why do we need this kind of thinking in our fire use

and fire suppression organizations?

By Tim Sexton

Fire Use Program Manager, USDA Forest Service

Workshop’s Keynote Speaker

Individually, I expect that you are all

seeking improvement in your performance.

Collectively, your organizations want you

here to improve their organizational

performance.

Managing the Unexpected and developing a

Aren’t we already there? Aren’t we already a ‘High Reliability Organization’?

Tim Sexton

“High Reliability Organization”... What does

it really mean to be a “High Reliability

Organization”?

As listed in this Managing the Unexpected

Workshop’s syllabus: “Less than their fair

share of accidents” is one of the traits of a

High Reliability Organization.

prescribed fire.

These improvements,

however, have therefore

come at very high prices:

human deaths or tremendous property loss.
Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization 9

In the fire suppression program:

• The 1910 fires that swept the West

and resulted in nearly 100 fatalities.

Organized fire suppression

commenced after that year. The

subsequent suppression program

became very successful in

achieving its stated goals.

• The Mann Gulch and Inaja Fires—

that claimed the lives of 25

firefighters—gave us the Ten

Standard Firefighting Orders.

• Only after the Loop Fire killed 12

firefighters, did we develop

Downhill Line Construction

Standards.

Collectively, these wildland fire use and

prescribed fire events resulted in significant

enhancements in staffing, funding, planning,

training, and implementation procedures

within the fire use program area.

It is important to note that, in most cases,

individuals had already recognized

inadequacies and had made changes

locally—averting negative and unwanted

consequences. The prescribed fire program

appears to go through cycles of repetitive

errors due in part to our failure to

incorporate this local knowledge gained from

minor events prior to experiencing a major

event.

Organizational Improvements Stemming From “Accidents” or Escapes

• The 1970 Southern California

fires claimed both public and

firefighter deaths as well as

enormous property losses—and led

to the development of our Incident

Command System.

• The Airtanker Program is currently

undergoing reform to address

aircraft airworthiness after the lives

of 100 airtanker pilots and crew have

been taken during the past 40 years.

In the fire use program:

• Canyon Creek (U.S. Forest

Service –Wildland Fire Use).

• Mack Lake (U.S. Fish and

Wildlife Service – Prescribed Fire).

• Lowden (Bureau of Land

Management – Prescribed Fire).

• Cerro Grande (National Park

Service – Prescribed Fire).

• Sawtooth (Bureau of Indian Affairs

– Prescribed Fire).
10 Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization

There is much yet to learn. And there are

many improvements to be made.

At this time, our fire use program is

expanding rapidly to meet the needs of an

escalating fire risk problem.

In 1999, the national “coarse scale

assessment” indicated that far more than half

of our federal lands are at elevated risk of

unwanted wildfire (Fire Regime Condition

Classes 2 and 3). Subsequent modeling

associated with the Cohesive Strategy

indicate that this problem is only getting worse.

Even under current levels of treatment, we are

losing ground each year.rescribed fire.

To halt the increase in Fire Regime Condition

Classes 2 and 3, the modeling indicates we

will need to treat twice as much as we are

treating under this year’s fuel reduction

program. The modeling also indicates that to

make significant improvement in the

wildland fire risk situation on this country’s

federal lands, we would need to quadruple the

size of the current fuel reduction program.

The problem we face is huge. It is only

becoming bigger and bigger.

True Story

Institutional Learning: Uh, What’s That?

Recently, a longtime Forest Service fire employee

recognized a problem with institutional learning.

His son, now a district-level fire employee, indicated he

was having trouble developing prescriptions for burning in

western juniper.

Twenty years before, the father had served on the same

Forest. He had a great deal of experience burning juniper

there. During the intervening years, however, this Forest

had “lost” the accumulated knowledge of the prescription

parameters that worked well in western juniper.

It became apparent to this father—and son—that the

agency needs to adopt a better framework for facilitating

“learning-from-experience”.

Isn’t it time we develop an organizational framework that can adapt an

evolve without large losses as a prerequisite?
Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization 11

• Mostly small units of up to 40 acres.

• Fuels within the burn unit were

typically more flammable than

outside the unit. Spot fires therefore

occurred in less flammable fuel and

selfextinguished or were relatively

easy to suppress.

• Burning was completed within a few

hours. Consequently, weather

forecasts were relatively accurate

from start to finish.

Complexity of Situation is Increasing – Today’s Wildand Fire Situation

Is Very Different from Our Past Institutional Fire Use Experience

The wildland fire situation in which we find ourselves today is very different from much of our

institutional experience in fire use.

Historically, our prescribed fire program was primarily slash burning. Characteristics of that

former program included:

• Staffing plans were for only one or

two days.

• Burn unit locations were typically

far removed from communities and

other important values-to-protect.

• Readily available help (should

something go wrong) was usually

nearby in the form of logging

equipment and crews.

The majority of the Managing the Unexpected Workshop participants are

prescribed fire and fire use practitioners from a variety of agencies.

Tom Iraci Photo USDA Forest Service
12 Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization

• Units are much larger. We are

encouraging landscape-scale

treatments of up to thousands of

acres. (In FY04, The Forest Service’s

Southeast Region’s burn units

average more than 700 acres in size.)

• Fuels outside the burn unit are

usually just as flammable as those

within the unit. Consequently,

spotting has become a much greater

threat to control efforts.

• Because of this larger scale, many

of these burns occur over a period of

days or even weeks. Weather

forecasts become much less

accurate when extended over

periods of more than 2 or 3 days.

Staffing plans for firing, holding,

Our national leadership believes you can make the

difference in these outcomes if you help us become a

“High Reliability Organization.” An organization that learns

and adapts before it experiences catastrophe.

Our current and future program is fundamentally different in many ways:

In addition to these program changes, we are also experiencing many

environmental changes that increase our program’s complexity

• Climate change.

• Extended droughts.

• Increase in widespread insect

and disease outbreaks.

and mop-up become much less

certain and more difficult to

maintain as duration of the burn

lengthens.

• Much more of our burning is

occurring in proximity to

communities and other improvements.

The rapid expansion of the

wildland-urban interface and the

need to treat hazardous fuels around

these communities contributes to this

dilemma.

• Due to the decline of the timber

industry, trained and experienced

crews and equipment are not as

available locally. This makes it more

difficult to obtain support resources in

a timely manner when things go wrong.

The following conditions continue to conspire to produce fire environments beyond our

experience base:

• Forest densification.

• Invasions of highly flammable

exotic species such as cheat grass

and saltcedar.
Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization 13

Escaped Cerro Grande Prescribed Fire, May 2000

“Coming back here reopens the book on the darkest chapter in

my life. But if my participation here today helps prevent any of

you from going down the road we did four years ago, it will all

be worthwhile.”

Al King, Bandelier National Monument FMO in 2000,

on the 2004 Managing the Unexpected Staff Ride.

Photos by Steven G. Smith/Albuquerque Tribune

This Workshop

 – and You – Can

Help Us Become

a High Reliability

Organization

The wildfire problem is huge and

getting bigger.

It is complex and getting

morecomplex. To avert disasters

of biblical proportion, we need to

become organizations that adapt

and evolve in anticipation of

catastrophes rather than as

a result of catastrophes.

Within our programs, we are

involved in a tremendous

undertaking with potential

outcomes could be enormously

positive—or negative.

Our national leadership believes

you can make the difference in

these outcomes if you help us

become a “High Reliability

Organization.” An organization

that learns and adapts before it

experiences catastrophe.

Thank you for your time. Have a

great week exploring these

concepts.

Tim Sexton
14 Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization

Tom Iraci Photo USDA Forest Service

If you depend too much on a simple set of

expectations, unusual events can develop to

more serious levels—before you even notice

them.

Therefore, people in High Reliability

Organizations try to see more, make better

sense of what they see, and remain attuned to

their current situation. They do this through

five central processes that encourage:

IV Day One: Managing the Unexpected

How do you organize for high performance in a setting where the

potential for error and disaster can be overwhelming?

This chapter shares key points from Karl Weick and Kathleen Sutcliffe’s Managing the

Unexpected and High Reliability Organizing initial

all-day presentation and discussion.

‘Mindfulness’ is the Passkey into High Reliability Organizing

Weick and Sutcliffe have discovered that

the following five processes repeatedly

surface in organizations who successfully

contain errors. In other words, High

After Karl Weick and Kathleen Sutcliffe kicked off the workshop’s first day by presenting ideas about

High Reliability Organizations, mindfulness, and managing the unexpected, they joined the workshop

participants for the rest of the week “clarifying ideas, answering questions, and learning” says Weick.

• A self-consciousness about the

validity of their beliefs.

• A willingness to question, reaffirm

update, replace, and learn from all five

of these processes.

Thus, these five diverse processes resonate

together by producing the passkey into

Weick and Sutcliffe’s High Reliability

Organizing. They call it “Mindfulness.”

The Five Central Processes that Produce “Mindfulness”

Reliability Organizations are attentive

to: 1) Failures, 2) Simplifications, 3)

Operations, 4) Resilience, and

5) Distributed Expertise.
Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization 15

Tom Iraci Photo USDA Forest Service

1. A Preoccupation with Mistakes/Failure

Systems with higher reliability: worry chronically that analytic errors are embedded

in ongoing activities, and that unexpected failure modes and limitations of foresight

may amplify these analytic errors. These high reliability systems have been

characterized as “consisting of collective bonds among suspicious individuals,” and

“as systems that institutionalize disappointment.” In the words of the head of

Pediatric Critical Care at Loma Linda Children’s Hospital, to institutionalize

disappointment means: “to constantly entertain the thought that we have missed

something.”

2. A Reluctance to Simplify

To truly get the work done, all organizations must ignore most of what they see. The

crucial issue here: whether their simplified diagnoses force them to ignore key

sources of unexpected difficulties. Mindful of this tradeoff’s importance, systems

with higher reliability restrain their temptations to simplify. They do so through such

means as diverse checks and balances, adversarial reviews, and cultivation of

multiple perspectives.

In introducing

people to High

Reliability Organizing

concepts, Kathleen

Sutcliffe explains that

these concepts

don’t really describe a

“static organization”

per se, but rather are a

set of organizing

principles—a dynamic

process rather

than an entity.

These five processes, then, serve as hard won lessons in the continuing struggle for the

necessary “alertness” that High Reliability Organizations face every day:
16 Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization

At the Diablo Canyon nuclear power plant, people preserve complexity in their

interpretations by constantly reminding themselves of two important themes:

• We have not yet experienced all potential failure modes that could occur here.

• We have not yet deduced all potential failure modes that could occur here.

3. Sensitivity to Operations

People in systems with higher reliability tend to pay close attention to operations.

Everyone—regardless of his or her level—values organizing to maintain situational

awareness. Resources are deployed to enable people: to see what is happening; to

comprehend what it means; to project into the near future what these understandings

predict will happen. In medical care settings, sensitivity to operations often means

that the system is organized to support the bedside caregiver.

Tom Iraci Photo USDA Forest Service

IN THE FIELD – Karl Weick and Kathleen Sutcliffe share a lighter moment on the Staff

Ride with Matt Snider, lead presenter at Stand Two. Snider was the Ignition Specialist on

the 2000 Cerro Grande Prescribed Fire.
Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization 17

4. A Commitment to Resilience

While most systems try to anticipate trouble spots, higher reliability systems also pay

close attention to their capability to improvise and act—without knowing in advance

what will happen.

These reliable systems spend time improving their capacity to:

• Do a quick study.

• Develop swift trust.

• Engage in just-in-time learning.

• Simulate mentally.

• Work with fragments of potential relevant past experience.

5. A Deference to Expertise

Reliable systems let decisions “migrate” to those with the appropriate expertise to

make them. Adherence to rigid hierarchies is loosened—especially during

high-tempo periods. In this way, a much better matching of experience with problems

is achieved.

“High Reliability Organizations try to understand the systemic

reasons for why the accident happened—rather than

focusing on punishing the individual.”

Kathleen Sutcliffe

‘Mindful’ is Paying Attention in a Different Way

“To better understand what we mean by “mindfulness,” Kathleen Sutcliffe explained to

workshop participants, “it’s sometimes easier to think of the opposite: mindlessness.

‘Mindlessness’ is being tuned out, being on autopilot.’‘Mindful’ is being aware of the

context, of paying attention in a different way:

• You STOP concentrating on those things that confirm your hunches, are pleasant,

feel certain, seem factual, and explicit—and that others agree on.

• You START concentrating on things that disconfirm, are unpleasant, feel uncertain, seem possible, are implicit—and are contested.”
18 Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization

“Weick and Sutcliffe challenge us as managers to

maintain ‘awareness of discriminatory detail’ and

focus on our ‘ability to discover and correct errors

that could escalate into a crisis.’

At the operational level, we have reacted to errors

quickly. Over the past several years—in response to the

1990 fatality Dude Fire, the 1994 fatality South Canyon Fire, the 2000 Cerro Grande prescribed fire escape, and the 2001 fatality Thirtymile Fire—we have

focused on policy and process.

Our fire policy has changed. Our burn plans are

more complete, our fire management plans are more

detailed, and our large-fire situational assessments

are more thorough.

I do not wish to demean any of these

improvements. However, I believe that we need to go

beyond the fixes that we have traditionally relied on.

The necessary steps will represent a profound

change in how we plan and execute the high-risk,

high-consequence fire program that we are charged

with leading.”

Jerry Williams, Director

Fire and Aviation Management

USDA Forest Service, February 2002

To Be Mindful

is to ‘See More Clearly’’ –

Not to Think Harder and Longer

• See where your model didn’t work,

or see indicators you missed that

signaled expectations weren’t

being filled – 1. FAILURE.

• Strip away labels and stereotypes

that conceal differences among

details – 2. SIMPLIFICATION.

• Focus on what is happening here

and now – 3. OPERATIONS.

• See new uses for old resources

through improvisation and

making do – 4. RESILIENCE.

• Discover people who understand

a situation better than you do and

defer to them – 5. EXPERTISE.

At the end of the week, a widespread workshop participant comment was how

beneficial it was to have the external “experts” sharing their insights and knowledge.

Tom Iraci Photo USDA Forest Service
Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization 19

1. Reporting Culture

What gets reported when

people make errors or experience

near misses?

2. Just Culture

How do people apportion blame

when something goes wrong?

Weick and Sutcliffe used several “real world”

examples of successful High Reliability

Organizing (e.g. aircraft carrier flight deck

operations), as well as organizations who

weren’t mindful and developed “blind spots”

in their attention to the aforementioned five

High Reliability Organizing processes.

As pointed out in the Columbia Accident

Investigation Board Final Report (Aug. 26,

2003), NASA made several actions and

inactions that most likely contributed to the

February 2003 Columbia Space Shuttle

disaster and tragic deaths of its seven-member

crew.

“NASA’s employees did several things that

moved them away from paying closer

attention to failure,” Weick, who served as a

consultant to the Columbia Accident

Investigation Board, told the workshop

audience. “They were less than a High

Reliability Organization. They did not

reliably return the Columbia back to earth.”

Among other failures, oversights, and

inaction, Weick said the agency was

insensitive to operations. It did not mobilize

to cope with an unforeseen situation. It did not

use experts wisely.

Reluctance to Simplify: Information

regarding the Columbia’s potential takeoff

damage was filtered as it moved up through

the organization. Top management,

therefore, ultimately received a simpler view

of the problem than the “lower level”

employees.

Preoccupation with Failure: NASA did not

use the previous fatal Challenger disaster as a

case to promote learning (as the Navy did with

its organization’s Thrasher and Scorpion

disasters).

Examples of Organizations Failing to Be Mindful

How to Work Toward a Mindful Culture

Strive for what noted psychologist and author James Reason calls an “informed culture”

that creates and sustains intelligent wariness. Informed cultures result from these four

coexisting subcultures:

“High Reliability Organizations try to understand the systemic reasons for why the accident

happened—rather than focusing on punishing the individual,” Sutcliffe explained to the

workshop participants.

3. Flexible Culture

How readily can people adapt to

sudden and radical increments in

pressure, pacing, and intensity?

4. Learning Culture

How adequately can people

convert the lessons that they have

learned into reconfigurations of

assumptions, frameworks, and

action?
20 Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization

Weick lamented that after the earlier tragic

Challenger Space Shuttle disaster, NASA

failed to put any new information back into its

training processes.

He applauded the federal fire agencies for

learning from their major mishaps.

Kudos to Federal Wildland Agencies for Honing Their Learning Curves

Unfortunately, most organizations have a

tendency to ignore or overlook their failures

(which suggest they aren’t competent) and

focus on their successes (which suggest they

are confident).

Therefore, High Reliability Organizations

encourage people to report problems.

All HRO’s Heed Close Calls and Near Misses

High Reliability Organizations:

• Regard close calls and near misses as a kind of failure that reveals potential danger, rather than as

evidence of the organization’s success and ability to avoid danger. They pick up on these potential

clues early on — before they become bigger and more consequential.

• Know that small things that go wrong are often early warning signals of deepening trouble that

provide insight into the health of the whole system.

• Treat near misses and errors as information about the health of their systems and try to learn from

them.

• Are preoccupied with all failures, especially the small ones.

• Understand that if you catch problems before they grow bigger, you have more possible ways to deal

with them.

“You people pump information back into

your organizations,” Weick told the Managing the Unexpected Workshop audience.

“You’re not afraid to look at your tragedies,

your disasters. You try to learn from them.”

High Reliability Organization Employees are Encouraged to Report Problems

They also simultaneously ensure “psychological safety” to their employees.

Thus, employees know it’s acceptable to bring

up “bad stuff”—to report failures.
Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization 21

Tom Iraci Photos USDA Forest Service

To truly adopt the High Reliability Organizing concepts requires repeating and learning them over

and over—fostering “deep learning” with continuous critical feedback.

High Reliability Organizations:

• Shift decisions away from formal authority toward expertise and experience.

• 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 expertise during high-tempo times. It migrates up as

well as down.
22 Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization A Mindful Infrastructure for High Reliability A Min

d

f

ul In

fra

s

tru

c

t

ure f

or Hig

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elia

bilit

y

Capabilityto Discoverand ManageUnexpectedEvents

ProcessesPreoccupationwith FailureReluctanceto SimplifyInterpretationsSensitivityto OperationsCommitmentto ResilienceDeferenceto Expertise 

Mindfulness Reliability
Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization 23

Tom Iraci Photo USDA Forest Service

Sensemaking Versus Decision-Making

“If I make a decision, it is a possession. I take pride in it. I tend to defend

it and not 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

(burning) period.”

Paul Gleason

Karl Weick used this quote of Paul Gleason’s

in his presentation. “Paul was a real inspiration to me,” Weick said.

(Gleason was also involved in the Cerro Grande

Prescribed Fire and served as Incident Commander

on its initial Type 3 suppression operation.)

INTERNATIONAL APPEAL – The diversity of the participants—from various agencies and

even countries—enriched the workshop. Pictured here (center foreground) is David Clancy, the

Occupational Health and Safety Officer for the Country Fire Authority at Mt. Waverley in

Victoria, Australia. Clancy is working on his Ph.D. on human factors in wildland fire.
24 Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization

Al King Matt Snider Mike Powell Edward Hiatt

They didn’t have to do it. Would you?

The four employees most intimately involved

with the planning and implementation of the

prescribed fire that escaped to eventually

become the infamous May 2000 Cerro Grande

Wildland Fire agreed to come back to

Bandelier National Monument—to Cerro

Grande itself.

For the benefit of the national prescribed fire

and fire use programs, Al King, Matt Snider,

Mike Powell, and Edward Hiatt—all

instrumental in the original Cerro Grande

prescribed fire—were asked by workshop

organizers to be the key presenters in a Staff

Ride designed, more or less, to scrutinize their

actions and decisions.

“It took a real strength and strong display of

courage for these folks to return here and

become so intimately involved in this,” said

Dick Mangan, Lead Workshop Organizer.

Keep in mind that—only four short years

ago—these four individuals had been the

target of numerous post-fire inquiries,

investigations, and reviews.

As reflected in Chapter VI of this paper, during

the post-field visit “Integration Phase,”

workshop participants—again and again—

voiced a unanimous theme: these four

individuals made the Cerro Grande Staff Ride a

true success.

“I saw a tremendous display of resilience by

these people who came here to share their stories

with us,” voiced one workshop participant. “I

hope their presence here was as helpful for them

as it was for me.”

V Day Two: Cerro Grande Staff Ride

How Can We Apply the High Reliability Organizing Concepts to

the May 2000 Cerro Grande Prescribed Fire?

Overall Consensus: These Four Provided Professionalism, Courage, and Class

Organizational Recovery

In the After Action Review at the week’s end, one

participant noted that an “unspoken objective” of

the four-day workshop had been another step

toward “organizational recovery” from the entire

Cerro Grande incident.
Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization 25

Tom Iraci Photos USDA Forest Service

Background

Three weeks prior to the workshop, all of the participants were mailed Karl Weick and

Kathleen Sutcliffe’s book Managing the Unexpected. They were also sent a

“Preliminary Study” of the Upper Frijoles Units 1 and 5 Prescribed Fire (now

commonly known as the “Cerro Grande Prescribed Fire”)—which escaped on May 4,

2000 to become the Cerro Grande Wildland Fire that evacuated 18,000 people,

destroyed 235 homes, and caused significant damage to structures and property on the

Los Alamos National Laboratory. The fire resulted in an estimated total of $1 billion

in damages.

Exposure to this Preliminary Study—which included a summary of the prescribed fire

project area and prescribed fire burn plan, conditions prior to the prescribed fire’s

ignition, and a chronology of events before and during the prescribed fire’s

implementation—was the Staff Ride’s first phase.

Thus, the Staff Ride’s actual on-site field visit—which consisted of five separate

presentation and discussion stops (“stands” in Staff Ride parlance)—was enhanced by

the workshop participants’ in-depth knowledge via this Preliminary Study.

Three of the Staff

Ride “stands” were

located at the bottom

of Cerro Grande,

where fire snags

serve as a reminder

of the prescribed

fire’s transition to

wildfire.
26 Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization

Stand One

Ponderosa Campground, Bandelier National Monument

Lead Presenter

Al King, FMO at Bandelier during the Cerro Grande event,

who also served as Holding

Boss on this prescribed fire.

[King is now the National Park Service’s

Fire Safety and Prevention Specialist]

Discussion Topics

The history of fire in the area—including the nearby Dome and

La Mesa wildland fires; the Bandelier prescribed fire program

at that time; weather prior to the prescribed fire’s ignition.

Tom Iraci Photos USDA Forest Service

Staff Ride

The 85 workshop participants were divided into three groups who each left Santa Fe for

Bandelier National Monument in separate buses in 45 minute intervals on Tuesday

morning. By 4 p.m. that day, the last group had finished its session at Stand Five, the

final stop of the field visit portion of the Staff Ride.

Middle Photo – Al King kicks-off Staff Ride at Stand One with a

vista of the 1977 La Mesa Fire-scarred lands.

Top and Bottom Photos – Key ingredient in any successful Staff

Ride is the encouragement of reflection and

discussion by participants.
Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization 27

Stand One Summary

• In 1977, the La Mesa Fire was the first large wildland fire that burned onto Los

Alamos National Laboratory lands and threatened the town of Los Alamos.

• Bandelier National Monument’s prescribed fire program began in 1978.

• The 1996 human-caused Dome Fire was the second large fire to burn near and

threaten the town of Los Alamos. It served as a hazardous fuels threat’“wake up

call.” The Los Alamos National Laboratory began doing mechanical treatments on

its lands.

• In the aftermath of the Dome Fire, the “Interagency Wildfire Working Team” was

also formed. It joined the following agencies in an effort to make the general Los

Alamos area more defensible to wildland fire: The Department of Energy, Los

Alamos National Laboratory, Los Alamos County, Santa Fe National Forest,

Bandelier National Monument, New Mexico State Forestry, the Bureau of Indian

Affairs. This interagency group met every two weeks—including prior to the Cerro

Grande Prescribed Fire.

• As part of the Bandelier Fire Management Plan, Dr. Tom Swetnam, Director of the

University of Arizona’s Tree Ring Laboratory, performed a fire history study of the

area that revealed fire historically burned here on a 5 to 25-year return interval.

More than half of these fires occurred in the spring.

Tom Iraci Photo USDA Forest Service

“Coming back here reopens

the book on the darkest chapter

in my life. But if my participation

here today helps prevent any

of you from going down the

road we did four years ago, it

will all be worthwhile.”

Al King’s opening remarks at

Stand One
28 Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization

Tom Iraci Photos USDA Forest Service

“The Staff

Ride was

amazing,” said

a workshop

participant. “It

far exceeded

my

expectations

and was

helpful as an

example of

how and where

to apply

mindfulness.”

Stand Two

Meadow on south side of Highway 4,

across from Cerro Grande

Lead Presenter

Matt Snider, Ignition Specialist

on this prescribed fire.

[Snider is now the Fuels Technician/Fuels Captain

at Lassen Volcanic National Park]

Discussion Topics

Fuels, weather, firing plan,

holding plan, MMA, monitoring,

RAWs, phasing of burn.
Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization 29

“I came back here today for two reasons. One, I’m

hopeful that something I do or say might help

prevent any of you from ever going through what we

went through. And, two, for [the late] Paul Gleason.

Because of his emphasis on learning and teaching, I

know he would have wanted us to come back

here—to be a part of this. I know that wherever Paul

Gleason is today, he’s saying: ‘Way to go, you guys’.”

Matt Snider’s closing remarks at Stand Two

Stand Two Summary

• This burn’s planning and pre-ignition data are missing or

gone. [Shortly after the escape, during the initial

investigation process, Snider and the others had everything

in their offices packed up and taken away by federal Law

Enforcement Officers. None have seen any of these work

folders and records since.]

• Bandelier’s fire staff had a very close working relationship

with the supervisor’s office.

• Snider—and everyone involved in the prescribed fire—felt this was a good burn plan.

He had no qualms—nor sense of urgency—regarding the implementation of this burn.

• He had extensive experience burning in these fuel types.

• Even though the 10-person Black Mesa Bureau of Indian Affairs crew who showed up that

day to help with the burn had never worked here before, Snider said this did not seem

out-of-the-ordinary or risky.
30 Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization

Tom Iraci Photos USDA Forest Service

Stand Three

Meadow on north side of Highway 4,

with views of Cerro Grande’s top.

Lead Presenter

Mike Powell, Burn Boss on this prescribed fire and,

in May 2000, Bandelier’s acting AFMO.

[Powell is now the Prescribed Fire Specialist

at Lava Beds National Monument]

Discussion Topics

The ignition process; spot weather forecast; ignition

pattern; staffing; events up until 0600 May 5th;

dispatch discussion; holding crew actions.
Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization 31

Stand Three Summary

• When Mike Powell called Santa Fe Zone Dispatch at 0317 Friday (the burn was ignited at

2200 the night before) and asked for a Type 2 Crew, the (new to nightshift) dispatch

employee informed him he would have to speak with a supervisory dispatcher—who

wouldn’t be there for a few more hours.

• Because the 10-person Black Mesa BIA crew could no longer work due to fatigue, the

staffing plan failed and they needed to fix that. When Powell called dispatch back at 6 a.m.

no one answered.

• With Paul Gleason there, Powell’s “comfort level” was increased.

• Participant Question: Is it typical for your crew resources to work all day and then burn that

night? Mike Powell: No. We were pushing issues.

• They’d been having discussions with the Black Mesa BIA unit about getting crews to help

for several days. But by the day of the prescribed burn, Black Mesa’s regular fire crews had

all been dispatched to a faraway fire. Bandelier got “the last ten people they had available.”

Dispatch Dilemma

Burn Boss Mike Powell explains how it took nine critical hours

from the first time additional resources were requested

throughdispatch until they arrived on the prescribed fire.
32 Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization

Cerro Grande (“big

hill” in Spanish) rises

to 10,200 feet in New

Mexico’s Jemez

Mountains. The

prescribed fire’s

primary project area

was located between

the 9,000 to 10,000-

foot elevation.

Tom Iraci Photos USDA Forest Service

Stand Four

Meadow on north side of Highway 4,

with views of Cerro Grande’s top.

Lead Presenter

Edward Hiatt, Bandelier’s Fire Use Module

Lead Crew Member. (As planned, Al King who

helped implement the burn—joins Hiatt to add

information and answer questions.)

[Hiatt is now the Wildland Fire Use Specialist

at Grand Canyon National Park]

Discussion Topics

The prescribed fire escape; fighting the slop-over

from 1000 to 1300; ordering retardant.
Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization 33

Stand Four Summary

• At 1000 Friday, Edward Hiatt radioed Al King to tell him they needed a helicopter to

suppress the problematic slop-over.

• AType 3 helicopter arrives at approximately 1030 without the anticipated and much needed

suppression bucket. It drops off one crew member and departs for bucket.

• By 1100, the Santa Fe Hotshots arrive.

• The Type 3 helicopter, with its subsequent small bucket—at 10,000 feet—is not providing

the water amounts and saturation necessary to stop the slop-over’s spread. At 1255, an air

tanker is requested.

• King is surprised by how quickly the Black Mesa Crew experiences fatigue. “For their

safety, I knew we had to get them off the hill,” he says.

• Hiatt reminded how “contingency resources” procedures were different four years ago—

you didn’t have to have them on-site as you do today.’“Our ‘contingency resources’ for this

burn,” he says, “was a crew on the Forest and one in Albuquerque.”

Edward Hiatt recalled the series of events that unfolded with the prescribed fire’s problematic slop-over.

This included a late-arriving helicopter that came on-scene without its bucket. Karl Weick noted that

this—one of many delays—was a ‘small’ failure that collectively and cumulatively foreshadowed the

‘big’ failure of the prescribed fire escape. “Delays are often a valuable clue that the system is not

operating the way we thought it would and, therefore, we need to be even more alert for further

problems,” Weick explains.”“High Reliability Organizations are preoccupied with small, emerging, early

failures—also known as ‘problems.’”
34 Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization

Craig Martin

(l) and John

Hogan explain

how local

residents knew

that wind gusts

are common

near Cerro

Grande in May.

Karl Weick

believes that a

High Reliability

Organization

needs to be

preoccupied

with early hints

of the

unexpected—

like this windrelated local

knowledge.

Tim Sexton has an inside view into the Cerro

Grande aftermath by serving on its four

primary investigation teams.

Stand Five

Ponderosa Campground (same location as

Stand One)

Lead Presenters

Tim Sexton, served on the four primary

Cerro Grande investigation teams.

John Hogan, U.S. Geological Survey,

Jemez Field Station.

Craig Martin, Open Space Specialist,

Los Alamos County.

Discussion Topics

Where are we today? What is it like to

manage natural resources here

four years after this

prescribed fire’s escape?
Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization 35

John Hogan, an area resident, talks about the

positive involvement of local denizens in helping

rehab the fire’s burned area.

Stand Five Summary

• This prescribed fire escape galvanized national public attention and Congressional action.

• This event helped trigger the creation of the National Fire Plan.

• The people of Los Alamos “love” these mountains. So far, they have donated 50,000 hours

of volunteer time helping rehab the Cerro Grande burn area. Thus, some positive natural

resource learning opportunities are emerging from this event.

• Closer connections are also forming with the public and land management agencies in these

post-fire activities.

• However, to get back into a “burning mode” is still a “hard sell” in this community.

• Community members still say that the Bandelier employees who planned the prescribed

burn should have known about the “spring winds” that reportedly occur up there in May

and blast down into town. (An unpredicted wind event—41 hours after the escape

transitioned to a Type 3 suppression incident—triggered the fire’s run into Los Alamos.)

• This prescribed fire escape resulted

in an immediate national

moratorium on prescribed fire

ignitions. In addition, today, the

National Park Service has far more

stringent prescribed fire plan

requirements than the other federal

agencies—especially for fire

contingency resources.

• Statement from Staff Ride

participant: “We need to reward

our employees who initiate these

landscape-scale burns-rather than

provide so many disincentives.”
36 Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization

1. Praise and Empathy for

the Cerro Grande

Prescribed Fire Crew

“I work for local government fire

services in Los Angles County. I walked

away with a great respect for what you

all do in the [public land management

agencies]. If I understood it correctly,

you guys were ready to do this [Cerro

Grande] burn. I thought you had a good,

well laid-out plan. What you were trying

to do was very reasonable—what you

wanted to accomplish—your ultimate

goal of introducing fire where it hadn’t

burned since 1890.”

VI Day Three: Staff Ride Integration Phase and

Facilitated Group Discussions

A. Staff Ride Integration Phase

How Do We Apply the Lessons Learned on Yesterday’s Staff Ride to High

Reliability Organizing Concepts and to Our Current and Future Fire Use

and Prescribed Fire Program Organizations?

Final Phase of all Staff Rides:

The Integration Phase

A Staff Ride’s “Integration Phase” combines its first

two phases—the pre-study of the event and the

on-site field visit—into the final group discussion

climax that identifies lessons learned.

This open-ended “no holds barred” discourse was

held the morning after the all-day Cerro Grande

Staff Ride.

Workshop participants expressed a variety of lessons

learned, observations and insights. Subjects ranged

from the need to revamp the escaped prescribed fire

review process—to prevent employees from enduring

what the Bandelier National Monument staff

experienced, to various suggested changes to the

national prescribed fire program organization.

Professional Operation

“That whole prescribed burn was a very professional effort and operation. It was based on logic

and professional rationale. I think, in terms of what happened, it was easy for me to see how I

could have been a part of that—either had I been there, or looking back at my own personal

history, in which I have been a part of similar events.”

One-by-one, people verbally volunteered their

comments, many of which have been transcribed

and grouped here into ten separate subject

matter categories.

Kudos for the four former

Bandelier employees was

the predominant theme

voiced again and again

during the

Integration Phase.
Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization 37

_________________

“I believe the folks who conducted that

prescribed burn did everything that they

could. I probably would have made the

same decisions they made.”

Pivotal Experience

“I think the most pivotal experience for me

yesterday was Al King at the beginning of

the Staff Ride saying—really with all his

heart—how tough it was for he and the

others to come back. But he said they were

doing it to prevent any of us in this room

from going through what they had to go

through. That kind of took me through the

rest the day’s stations.”

Learn from Past Actions

“It is so important that we learn from our

past actions and experiences. It is

absolutely critical. That’s why I appreciate

you guys coming here this week to give

your side of the story. It’s been a real

pleasure working with you.”

I Would Have Done That Burn, Too

“What I came away with from the Staff

Ride was that I would have implemented

that burn, too.”

_________________

“I also could see myself in that same

position. I appreciate those folks coming

out and talking about it with us.”

An Incredible Feeling of Pride

“I’m looking at this crew [Al King, Matt Snider, Mike Powell, Edward Hiatt] who had the

willingness to come back here and share with us yesterday. I have an incredible feeling of pride

standing shoulder-to-shoulder with this group of individuals who had the courage to

return here to help us learn more about this event.

I mean this very sincerely. Just trying to imagine what you guys must have gone through . . . In a

way, you were responsible for lighting a burn that was ripping into one of the largest nuclear

facilities in the United States. A fire that was burning homes. I can’t even begin to imagine what

that must feel like. So, just knowing that you came back here to share your insights with us—it

sends shivers up my spine—to know that I work with people who are that professional. From a

High Reliability Organization concept, I wish someone higher up in the organization would have

stood up and said, ‘This crew did the best job they could.’”

Dave Thomas, Chair; Managing the Unexpected Workshop

Roy Weaver was a True Leader

“We’ve been remiss this week in not mentioning our Park Superintendent Roy

Weaver. He was the true dictionary definition of “Leadership.” To protect us, he

stood up and took accountability for what happened out on that hill.”

Matt Snider, Ignition Specialist on Cerro Grande Prescribed Fire
38 Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization

“Finding other people interested and actively working toward my same goals far exceeded

my expectations. There were some great people here!” enthused a workshop

participant at the end-of-week After Action Review.

How Do We Stop Playing

‘Blame Game’

“It seems like our investigation reports like to

play the“‘blame game.’ Our bureaucracies

like to do that. Maybe starting today, through

the Wildland Fire Lessons Learned Center

and this workshop’s concepts, we can begin

to look at these events as ‘disasters’.

In essence, that’s what Cerro Grande was. It

was a disaster for many people both directly

and indirectly involved. It was a disaster for

the agency. And it was definitely a disaster for

these folks who came back to share with us

this week.

After Cerro Grande I think we went

immediately to: Who did what wrong? We

didn’t act like a true High Reliability

Organization that would say: let’s really have

a fundamental desire to look at what

structures and processes we need to examine

to avoid this type of disaster in the future.

I think we’re on the right track, we’re moving

forward in the right direction. It comes down

to what Karl Weick and Kathleen Sutcliffe

talked about the first day. It’s going to take

repetition to develop a new organization

behavorial action. We need to practice this

over and over again. When the next crisis or

disaster occurs, we don’t want to go back to

our previous institutional behavioral

action. That’s our challenge.”

Wildland Fire Lessons Learned

Center Can Help Set Record Straight

“Even though I was on the Type 1 Interagency

Management Team assigned to the Cerro

Grande Fire, I learned a whole lot more about

this fire yesterday on the Staff Ride.

Tom Iraci Photo USDA Forest Service

2. Need to Change Investigation Process and Reports
Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization 39

What I now know about this prescribed

fire—what we learned yesterday—and what

the investigation reports say, are two

different things. We need to find a way to

set the record straight. I think the Wildland

Fire Lessons Learned Center could play a

big role in that.”

Beware of Perceptions and Opinions

Based on Reports

“I think we all realize the difference

between the investigation reports and some

of the data that we heard yesterday. It’s

been my experience on other staff rides—

after we’ve gone out on-the-ground and

really assessed what occurred—that we need

to be very careful how we formulate our

perceptions and opinions based on

thesereports.”

Need to Revisit Our Escape Burn

Investigation Process

“I firmly believe that the whole

investigation process needs to be revisited.

We all know mistakes are going to

happen—hopefully not on this scale. But

I’d like to think that when we conduct these

post-event processes—these investigations

and reviews—that we protect our employees

and not abandon them.”

A Few Courageous Leaders

“There are a couple of folks who had the

courage to stand up and support their people

[during past escaped prescribed fire

investigation processes]. People like Tim

Sexton have stood up and put their careers

on the line. They made sure the political

process didn’t run roughshod over people

who were trying to do the right thing. So

there are leaders among us who have the

courage and have the ‘right stuff’.”

How Do We ‘Grow’ More of This

Leadership?

“Some of the leadership that we wish would

be more present and more involved in

providing“‘psychological safety’ to you

folks might be more apt to occur if you told

them that this is important to you. This

workshop has the opportunity to provide

some of that impetus to our leadership. I

really appreciate the managers who are here,

who now have this possibility before them:

this opportunity to stand up and take

pro-active leadership positions.”

Tom Iraci Photo USDA Forest Service

Everyone has an opportunity to share impressions and ideas kindled by the Staff Ride.
40 Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization

Contingency Lines on Large Burns

“The main lesson I learned yesterday was

how they did this burn up on the top [of Cerro

Grande]—with the open end down on the

bottom. That kind of concerned me. When

we’re doing these large landscape-scale burns,

we need to look at how are we going to break

them up so we have contingency lines from

which we can shut the burn operation off

when—and if—we need to.

Communication Trap

“During the Staff Ride, in reviewing what

occurred prior to the prescribed fire, I saw

a communication trap. And I say this with

all respect to the people who were there

because I know this is hindsight. But those

meetings that occurred every two weeks

between the area’s fire managers may

have prevented some of the them from

getting together on the telephone and

‘I Lost Faith with the Organization’

“We need to develop a national policy to protect our employees in the aftermath of when we

have incidents like this. We need to protect them from the time the problem occurs through the

end of the investigation.

During this entire process, we need to attempt to minimize the amount of influence that politics

may have. We need to insure that a just decision is made on the employees’ welfare. We need to

find out all the facts. We don’t need to have an investigation that is politically deemed to be five

days and then move on to a decision before all the facts are even collected [criticism of the first

Department of the Interior Cerro Grande investigation].

I’m reminded of the wonderful people out there in management who do what is right and not

what is normally ‘best’. People like Tim Sexton and Tom Zimmerman—and my [former] Park

Superintendent Rob Arnberger and my [former] Chief Ranger Steve Bone. Those guys were

there for us. They put everything on the line.”

Ken Kerr, former Grand Canyon National Park Prescribed Fire Manager, third

generation Park Service employee. At the same time the 2000 Cerro Grande

escape occurred, he simultaneously had a landscape-scale burn which escaped

and burned 14 thousand acres and cost $10 million to suppress.

While he said he hadn’t planned to speak during the Integration Phase, a

sometimes emotional Kerr nonetheless stood up and took the microphone.

“What you guys [the four Bandelier veterans] went through deeply affected

me. As your investigation unfolded, ours did too. We were also under a

national investigation team in which a number of different individuals from

a variety of agencies came in to review what we were doing. It was a very

tough experience. By the grace of god, we didn’t have any homes to burn up.

We didn’t hurt anybody. We were very fortunate.”

In the aftermath of the agency’s overall reactions to these prescribed fire escapes,

Kerr—whose family had devoted a total of 75 years working for the Park

Service—left the agency. Kerr laments: “I lost faith with the organization.”

3. Constructive Criticism on this Prescribed Fire
Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization 41

talking to each other in a more immediate

sense . . . But because they knew they’d be

seeing each other in a couple weeks—they

A Deference to Expertise?

“Everybody yesterday agreed that there was

good communication on that prescribed fire—

and I absolutely believe that. They all also

said that it was very comforting having Paul

Gleason there. Obviously, I know that would

have been very comforting to everybody in

didn’t do this. So on the surface, it’s a great

plan to get together every couple weeks. But

it may have been a communication trap.”

4. Paul Gleason’s Influence – Positive or Negative?

A Passion for Learning

“After the Staff Ride someone asked Matt Snider what his motivation was to come here

and speak. He answered that that’s what Paul Gleason would want us to do. I also

believe this is true. One of Paul’s lifelong passions was being a student of fire—and he

tried to instill that passion in others. In reflecting back, I think that passion for

learning and being a student of fire was with us yesterday. Hopefully, now, we can all

have that passion as we continue through this week. We can try to tie-up some loose

ends and bring some sense to all of this. And we can come out with new ideas that we

can take back to our own units and organizations to implement.”

Al King, Bandelier FMO during the Cerro Grande Prescribed Fire

Paul Gleason, the National Park

Service’s Wildland Fire Management

Specialist for the Intermountain Regional

Office at the time of the Cerro Grande

Prescribed Fire, was serving as “fire

observer” on this burn. Fourteen hours

after ignition, due to extenuating

circumstances, the FMO and Burn Boss

decide to transition Gleason to Burn

Boss. Gleason was a widely acclaimed

veteran in wildland fire and fire use,

known internationally for his fire skills

and savvy. (In February 2003, at 57, he

died of cancer.)

this room. It certainly would have been

comforting to me, had I been there. I’d feel

that same way, too. But because of having that

high level of expertise there—would there be

some automatic deference to that expertise? I

don’t know if this actually happened, I’m just

wondering if that may have been an issue

here.”

Gleason Mindful – Dispatch Wasn’t

“In response to comments about Paul Gleason.

I think this was a different, positive model for

having an ‘esteemed expert’ on site. Paul

exemplified an esteemed expert who was right.

He was being mindful. What happened to

Paul was he ran smack up against an

unmindful bureaucracy. And that can happen

to any of us. Those people [Bandelier fire

staff] made sure those contingency resources

were there right up until the time they

implemented that burn. But when they needed

those resources, they ran into mindlessness

and chaos when they actually called for those

resources.”
42 Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization

Tom Iraci Photo USDA Forest Service

Karl Weick: An Ill-Advised Deference to Paul Gleason?

“The thing that really surprised me [on the Staff Ride] was that I came here, like

many people did, with enormous respect for Paul Gleason. And, now, I really

understand—even more—the reverence in which people hold him and his

expertise.

What struck me yesterday was the number of times I heard things like ‘Paul was

everywhere’; ‘Paul said to me, look we’ve got to do something’; ‘Paul says go get

some sleep’ . . .

So there’s an interesting tension for me around the issue that it’s possible to have

someone so venerated, with so much perceived expertise, that if anything was

going rotten on this fire, he’d know it and he’d speak up. Therefore: If I have any

kind of nervousness, but Paul isn’t nervous, we must be in good shape.

I guess I haven’t seen that possibility quite as clearly before. And it’s just a

possibility that I perceived yesterday in trying to put together all the pieces.”

Karl Weick

Karl Weick and Kathleen Sutcliffe participated and shared their

observations and insights during the Integration Phase.
Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization 43

Lessons Learned from Cerro Grande

“I was struck by the fact that some of the

changes and issues we deal with today are a

direct result of Cerro Grande. In some cases,

we may not be dealing with certain issues

today because we made some of these

institutional changes as a result of Cerro

Grande.”

I Congratulate You

“I thought I heard you say yesterday that you

5. Positives from this Prescribed Fire

Inadequately Prepared to Make

Decisions – Using Wrong Models

“When I listen to some of the data that went

into making those decisions regarding that

prescribed fire, it reinforces the very cynical

outlook I have about us, about our profession.

Specifically, how inadequately we prepare

ourselves to make our very complex

decisions. We are continually using models or

modeling concepts that are developed for

wildfire suppression and try to adapt them

into a prescribed fire setting— particularly

with the use of the Haines Index.”

Taking Risks – Yet No Rewards

“What I saw yesterday was a difficulty in

analyzing risk. Everything we do is how we

look at risk and how much risk we are willing

to take. But it is very difficult for us to get a

had two crews in place. But up there on that

east flank you only had two people to cover

it. I have a lot of respect for what you do.

You only had 30 people on that entire fire.

When we [local government fire services

in Los Angles County] call for a “first

alarm brush,” we have 141 people respond.

Yes, I have a lot of respect for what you

do. It boggles my mind the kind of

work you accomplish with the limited

resources that you have. I walk away

with a great admiration for you. I

congratulate you.”

true handle on what the risks are that we are

taking. Why are we so willing to take these

risks? Other than it’s just our job to do this.

What rewards or what benefits are we getting

for going out there and taking that risk?

In terms of the [Cerro Grande] prescribed fire,

I would have taken that risk, too. Yes, I am a

risk taker—as most of the people in this room

probably are. But why are we taking this risk?

We don’t reward people for taking these risks.

What rewards do we get? Our agencies

certainly don’t reward us for taking this risk.

They only come out and look when there has

been a problem. They don’t come out and look

at the good successes. How many workshops

do we have in which we get together to look at

what we have accomplished? None. We only

look at problems. We need to start rewarding

people for taking risks—even when

circumstances go bad.”

6. Criticisms of the National Prescribed Fire Program
44 Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization

Landscape-Scale Multi-Day Burns

and Unpredictability of Weather

“One thing that struck me yesterday—that’s

been gnawing on me for several years—is that

once we get beyond about two days from our

weather forecasts, we’re really susceptible to

unknowns. It’s been my experience that I can

trust the weather forecast for about 48 hours.

Beyond that it’s a crapshoot. As we start to go

more and more toward landscape level and

multi-day burns, we’re really headed into a

gray area. It really makes me wonder where

we’re going in the future and how we’re going

to accomplish our target goals.

Sometimes with the situations we are dealt,

due to the shape of the landscape and

ecosystems—how we have so much

Condition Class 3 lands that we’re trying to do

something with—the tendency for a lot of

agencies—mine included—is to go out there

and fix everything right away. I believe there

is also a political emphasis to do this. And I

don’t think that’s right. That’s not what we

should be doing.

We have all these areas that are suppose to

burn, for instance, once every 5 to 10 years

that haven’t had any fire for 100 years. So we

try to go out and meet all of our objectives and

return it back to that 5 or 10 year burn cycle—

all in one burn. In doing so, I don’t think that

we’re doing the ecosystem right. And I don’t

know if we’re doing our personnel right—

asking them to do that. Trying to meet all our

objectives all at once might be something we

need to reconsider.”

Improve Prescribed Fire Teaching

“I was reminded again yesterday of the

inadequacy of the National Prescribed Fire

curriculum. It needs to be adjusted and

overhauled. It doesn’t address landscape scale

burning at all. There is no book on

landscape-scale prescribed burning. Perhaps

we should all think about that today in our

future efforts to put a better prescribed fire

program together. To help the people that will

be coming up behind us. It’s our job to grow

the best fire management programs that we

possibly can.”

Need Prescribed Fire Paradigm

[From a municipal fire chief’s perspective.]

“Are there any risks that are acceptable? . . . Is

Become Better at Anticipating the Surprises

“In our work we think about the idea that you can try to anticipate as

much as you can. But as you implement prescribed fire, you certainly are

not going to be able to anticipate everything. Whether there is a certain

risk that you are willing to live with is one thing. But there is also really

focusing on that part of trying to contain or to act on the surprises that

do come up. That’s where I would be spending most of my time . . . Plans

do have their risk. Making sure you focus on the other end—on

containment and how you can recover from things that go wrong—is

where I’d also concentrate.”

Kathleen Sutcliffe
Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization 45

that written down anywhere? . . . If we’re out

doing prescribed fire, some are going to

escape. From a risk management

point-of-view, identifiable risks are

manageable risks: if it’s predictable, it’s

preventable. So do you want to keep the

system the same and define and accept what

your losses are going to be? Or do you want

Tom Iraci Photos USDA Forest Service

to fine-tune your system and find out what

your acceptable loss is going to be and then

find ways to break that down—via dispatch

systems, contingency plans, resources, etc.?

Right now, you’re going out there with a

suppression attitude/paradigm. You need to

change that paradigm. You need to change to

a prescribed fire paradigm.”

Using the Wildland Fire Lessons Learned Center to

help spread the word on this workshop’s findings was

voiced several times during the Integration Phase.

7. Feedback on the 2000 Santa Fe Dispatch Organization

Significant Systemic Failure

“Based upon what we heard yesterday and what we read before we came here, I believe we had

a significant systemic failure on this prescribed fire: the dispatch organization and its response

to the burn boss. Unfortunately, I’ve also dealt with this several times where I work.

It is not the responsibility of the dispatch organization to determine whether or not resources are

needed—or how they will be paid. That’s a question that is up to the agency administrators and

the budget and fiscal folks.

That burn boss should have been responded to immediately. And they should have received the

resources they needed. Whether or not it was a prescribed fire is irrelevant. What is relevant is

that there was fire just over the ridge from the Los Alamos National Laboratory. Having to check

with one’s [dispatch office] supervisor in that situation is a time lag that isn’t necessary. I think

that’s the main thing I’ll take back home with me.”
46 Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization

Staffing Levels

“I’m a local government fire chief. We do

micro burning—on a very small scale. After

the Staff Ride, what struck me was that on our

burns we staff with 3 or 4 times the people you

do. You need to take a look from a risk

management point of view at how you’re

staffing and your contingencies. Are they in

place to do the job? I don’t know how you

guys do this. It seems like you really need to

determine: do you truly have enough folks on

the ground to do the right job?”

Contingency Resources

“What struck me really hard yesterday—and

it’s still a huge problem for us—is the concept

8. Lack of Resources

Include Communities

“We need to start including our communities as part of our team. As we begin to do that,

communities will support us and be behind us—even when things go bad.”

Working Together Internally

“I’ve begun to think more and more about our organization being a lot like that aircraft

carrier flight deck we studied Monday . . . In my own program, I’m going to work to get my budget

people, my dispatch people, my agency administrator, all on the same side. To look at ourselves

as a true High Reliability Organization will be measured in how well we respond when we have

an escape.”

9. Stakeholders

Need to Educate the Public

“It seems like you should be asking the question:“‘How can we educate

our other stakeholders about the risks involved with prescribed fire?’

There need to be efforts to educate the public about risk. That stood out

yesterday as being very important.”

Kathleen Sutcliffe

of contingency. We recently had a big rug

ripped out from under us with the air tankers.

How many of us have written burn plans

where that’s the contingency—to load and

run retardant? Where are we going to go now?

What is our contingency? L.A. County can

call on first alarm and get 141 people. On the

[Cerro Grande] prescribed fire we were only

asking for one hand crew. And we couldn’t

get it. Where are our contingencies and what

are they going to be in the future?

I’m really concerned about how we are going

to play this game out with the dispatch

organization.”
Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization 47

Focus was on Learning

“The Staff Ride exceeded my best case scenario. I believe

the reason for its success was the participants. You guys were

really engaged. You asked good questions. Your focus was on

learning. There was a lot of good dialogue. I really

appreciate that. I felt very comfortable with you.”

Al King, Bandelier FMO

during the Cerro Grande Prescribed Fire

Difficult, Challenging, Emotional

“I want to say how impressed I am that you

are doing this. That you are trying to learn

from these experiences. I know it is difficult

and it is challenging and it is emotional.

I think you will learn a lot from this.”

Kathleen Sutcliffe

Dick Mangan, Lead

Workshop Organizer,

moderated the Staff

Ride’s vital third

component: The

Integration Phase.

Safe Forum for Staff Ride Presenters

“One of the presenters yesterday said how they were thankful that they had an opportunity to tell

their side of this event. Certainly, considering all the liability that is surrounding these folks and

their agencies, it’s understandable how they might not want to say a lot. But it’s important. It’s

important to them. And it’s important to us as professionals to hear their side—especially

presented in a way in which these people can feel safe doing this.”

Other Cerro Grande Staff Ride Possibilities

“It’s important to remember that there was more that transpired at Cerro Grande than this

prescribed fire. While we focused on the prescribed fire on this Staff Ride, we really have multiple

stories to tell, to examine. The Type 3 and the subsequent Type 1 wildland fire event also led to

the end result that was so tragic. It wasn’t just solely that prescribed burn.”

10. The Staff Ride as Learning Tool

Best Way to Learn

“From a lessons learned perspective, folks came up to me yesterday and

said that from all the different ‘lessons learned’ activities that they’ve

done, this—the Staff Ride—had been the best way for them to learn.”

Paula Nasiatka, Manager

Wildland Fire Lessons Learned Center
48 Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization

1. Remembering what we have learned from the Cerro Grande

experience, what aspects of High Reliability Organizing do we

need to institutionalize?

2. What specific actions need to be taken for prescribed fire and

fire use organizations to become High Reliability Organizations?

3. What actions can workshop participants take to help make this

happen?

4. What about High Reliability Organizing works for you or your

home unit that you intend to apply immediately?

B. Facilitated Group Discussions

Discussing these Questions in Facilitated Settings

After the Staff Ride Integration Phase, workshop participants were introduced to these

(above) four key questions by moderators:

Wayne Cook

Fire Technology Specialist, Fire Sciences Laboratory

Missoula, Montana

Paula Seamon

Director of Fire Management and Training

The Nature Conservancy’s Fire Initiative, Tallahassee, Florida

Participants then dispersed into five (strategically pre-assigned) groups to discuss

and answer these questions in facilitated settings. Michael DeGrosky, CEO of the

Wisconsin-based Guidance Group, served as the lead facilitator/organizer for the

entire exercise.

All of the groups reunited at the end of the afternoon to present their summary

priority answers, insights, and High Reliability Organizing suggestions.
Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization 49

Summary Comments from Facilitated Group Participants

1. Remembering what we have learned from the Cerro Grande experience, what

aspects of High Reliability Organizing do we need to institutionalize?

• All five High Reliability Organization elements are important to

institutionalize.

• Prescribed fire and fire use organizations are currently doing all five

High Reliability Organization elements to some degree. Here’s what we can

do better:

∞ Use the After Action Review tool (daily/incident)

∞ Do High Reliability Organization (HRO) audit (from the

Managing the Unexpected book) with more people

• Important to point out day-to-day examples of how various aspects of High

Reliability Organizations are already being used.

• Be a historian—review of past events, successes and failures—through verbal

and written means (staff rides, etc).

Tom Iraci Photo USDA Forest Service

Lead facilitator Michael DeGrosky (center sitting) confers with four of the

workshop’s nationally-selected facilitators—both agency employees and private

contractors—in preparation for Wednesday’s facilitated discussion groups.
50 Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization

• We need more After Action Reviews versus investigative actions—at both the

large and small scale.

 • Prescribed fire and fire use organizations are currently doing all five

High Reliability Organization elements to some degree. Here’s what we can

do better:

 • Deferring to experience:

∞ Foster management understanding

∞ Foster experience after qualifications (continuing education)

 • Be a historian—review of past events, successes and failures—through verbal

and written means (staff rides, etc).

2. What specific actions need to be taken for prescribed fire and fire use

organizations to become High Reliability Organizations?

• Stop thinking about “failure” of program. In meantime, take steps like helping

people to understand risk, using intermediate goals, and using different

markers (e.g. restoration, processes, functions).

 • Need to look at close calls and near misses. After Action Reviews are currently used more in suppression—they can also improve the prescribed fire

and fire use organizations. Could add as appendix to burn plan.

• Training:

∞ Change paradigm to fit all five elements of High Reliability

Organizations at all levels.

∞ Change and improve national training courses.

• Community Education:

∞ Education with commitment to change for decision makers at all levels

to support High Reliability Organizations.

• Shift the paradigm from “agency/unit” to landscape.

• Review board and investigation procedures:

∞ Systemic focus

∞ Change negative to positive

• Pull expertise and local knowledge whenever you can, break down functions.

• Escape reviews need to build resilience, competence, confidence. They should

not be judgmental or punitive.

• Escape support team(s):

∞ Team concept

∞ Supporting people while they take risks
Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization 51

Tom Iraci Photo USDA Forest Service

“I liked the

multi-day

format, both to

let the concepts

gel and to allow

for productive

dialogue among

the workshop

participants,”

commented one

person in the

workshop’s

end-of-week

After Action

Review.

3. What actions can workshop participants take to help make this happen?

• Extend After Action Reviews from suppression to fire use/Rx fire.

• Encourage people to review this workshop information.

• Use Wildland Fire Lessons Learned web site to share common issues coming

up in After Action Reviews.

• Apply High Reliability Organization theory to local programs (Rx and Use).

• Weave High Reliability Organization concepts into all areas of training.

• Create a sub-committee of people affected by escapes to improve tone of

investigations.

• Advocate, apply, integrate, and institutionalize High Reliability Organization

processes in your own workplace.
52 Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization

Promoting and incorporating the High Reliability Organizing concepts from the home

unit workplace to the national level, including all areas of training, proved to be a

universal suggestion among the facilitated work groups.

Tom Iraci Photo USDA Forest Service

• Be a disciple of High Reliability Organizations.

• Challenge peers to take fire community/unit forward.

• Provide more workshops like this one.

• Form a group of practitioners to rewrite Wildland Fire Use/Rx interagency

guidebook.

• Weave High Reliability Organization concepts into all areas of training.

• Develop report from this workshop and disseminate at many levels across

agencies:

∞ Wildland Fire Lessons Learned website

∞ Fire training

∞ Fire Management for Leadership

• Work with the two prescribed fire training centers:

∞ Expand curriculum

∞ Develop new training

• Infuse High Reliability Organization concepts in fire plans and project

planning.

• Re-write curriculum/participate actively:

∞ Relaxation of rules re: retiree participation

∞ NWCG: Encourage them to consider new learning methods
Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization 53

“Having people

from different

agencies—both

federal and

municipal

governments—

and the openness

of the discussions,

helped achieve

common

concerns,”

said one

workshop

participant.

Tom Iraci Photo USDA Forest Service

4. What about High Reliability Organizing works for you or your home unit that you

intend to apply immediately?

• Utilize skills in the research community. Engage them in some of the

problems areas. Develop a process/infrastructure for filtering and

coordinating research.

• Encourage others to review materials from this workshop.

• Incorporate High Reliability Organization concepts into this year’s

readiness review.

• Work with Wildland Fire Lessons Learned Center to disseminate Cerro

Grande lessons.

• Commit to work with escaped fire review process.

• Incorporate High Reliability Organization into existing training plans.

• Look at burn plan contingencies.
54 Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization

The four-day Managing the Unexpected

Workshop’s full schedule prevented Karl

Weick and Kathleen Sutcliffe from

commenting to the larger group at the week’s

conclusion about:

• How the High Reliability

Organization ideas were being

used.

• Where there seemed to be High

Reliability Organization

misunderstandings.

• Where there were good examples

of the High Reliability

Organization principles.

VII Weick and Sutcliffe’s Follow-Up to Workshop

Participants

The following section is excerpted and

edited from Weick’s eight-page

follow-up commentary to the

Managing the Unexpected

Workshop participants.

Therefore, after the workshop, Karl Weick

e-mailed all the participants follow-up

comments that he and Kathleen Sutcliffe

wanted to share “in the hope that they might

be of some help if you are trying to adapt some

of these High Reliability ideas to your own

groups.”

Your discussions of “preoccupation with

failure” often missed a key point.

When you heard the word “failure” you

seemed to think “escaped fire.” And then you

went on to discuss how unfair it is that a

suppression effort never fails and yet any

prescribed fire escape is always a failure.

The word “failure” is clearly a red flag. We

understand your concerns. But what you

forgot is that High Reliability Organizations

1. ‘Preoccupation with Failure’ – You Missed a Key Point

are preoccupied with small, emerging, early

failures aka problems. (In other words,

“failures” in the sense of things not working

out exactly as expected.)

High Reliability Organizations see those

small failures as clues that the system is not as

healthy as they thought it was. Those early small

failures are also easier to deal with than the

full-blown failures. Thus, High Reliability

Organizations spend a great deal of time and

effort on catching stuff while it is still small.

Examples

A. Needed: Stronger Preoccupation with Failure

Cerro Grande was not the first time there had been problems with Santa Fe dispatch. But

the earlier problems persisted untreated and made it harder for the burn boss to do his job

at Cerro Grande. If there had been a stronger “preoccupation with failure,” people might

have diagnosed and dealt with that dispatch problem earlier.
Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization 55

B. ‘Small’ Failures Can Portend Likelihood of Bigger Failures

The Cerro Grande prescribed fire crew was told “help is on the way.” But delays

prevented this from occurring in a timely manner. A delay is a small failure. Delays are

often a valuable clue that the system is not operating the way we thought it would, and

therefore, we need to be even more alert for further problems.

C. Need to Make Strong Responses to Weak Signals

During the Staff Ride and workshop, we kept hearing the phrase “that fire was a wakeup

call.” The previous Dome Wildland Fire, for example, was also described that way. If it

takes something that big and that dramatic to stir you into action, then it’s not very likely

that you’ll do much of anything when there is a much smaller failure—like a late arrival,

a surprisingly exhausted crew, or an unanswered (dispatch) phone.

The whole point of a preoccupation with failure is that High Reliability systems make

strong responses to weak signals. If your mindset is that you only make strong responses

to strong signals, then you need to consider changing that.

D. Need to be More Preoccupied with Early Hints of the Unexpected

Here’s an example of what it sounds like when you’re NOT preoccupied with failure.

During the Staff Ride, a comment was made that firefighting personnel often failed to

solicit “local knowledge” of quirks in local weather.

In the aftermath of the Cerro Grande escape, local area residents said they knew that

sudden “wind spurts” were common in April and May. They contended that the “new”

federal fire people didn’t know that. And it was just such a spurt that was the severe wind

event on Sunday (after the incident had been declared a Type 3 wildland fire) that pushed

the fire into the canyon.

When it was suggested during the Staff Ride that burn bosses should pay more attention

to local knowledge, a (federal) administrator replied, “It wouldn’t hurt to check, and at

least try non-traditional ways to look at fire.” The sentiment that “it wouldn’t hurt to

check” has less intensity than is necessary to be preoccupied with early hints of the

unexpected. Remember that Slide Three in the handout said that what is crucial for

reliability is how strongly you disvalue mis-specification, misestimation, and

misunderstanding. If it’s really important to get local quirks in the weather right, it will

take more than “it wouldn’t hurt to check.”
56 Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization

Cerro Grande Prescribed Fire, Board of Inquiry Final Report, Feb. 26, 2001:

“The Cerro Grande Prescribed Fire had tragic results. Employees at all levels

of the National Park Service, including the management and staff at Bandelier

National Monument, have expressed deep regret for the impact it had on the

lives of those people in Los Alamos who experienced property loss.

We can and must gain from this experience.

We must use the lessons learned as a basis to improve and enhance the

prescribed fire program throughout the country and all agencies. For, indeed,

we will need to continue to employ these methods to protect life and

property in the future.”

In reflecting on the lessons he learned from

Cerro Grande, Paul Gleason said that a big

lesson was that “we do way too much

simplifying.” His example was that people

erroneously tend to lump complexity, which

is a logistical problem, and risk, which is an

environmental problem.

Therefore, when people lump these two

problems, neither problem tends to be handled

adequately.

2. ‘A Reluctance to Simplify’ – You Need to Practice

While it is true that it is more complicated to

pull those two problems apart and analyze

them separately, it is also true that fire itself is

complicated. And the whole point of simplification is that it takes a complicated analysis to

grasp a complicated event.

Several examples came up in discussions.

Examples

A. Needed: Stronger Preoccupation with Failure

Recently, people within your organization have become more reluctant to simplify what

they mean by “contingency resources.” “Contingency” used to mean that the resources

were available somewhere in the area—anywhere from minutes to hours way.

Now, however, you are beginning to refine the ways you describe and request

contingency resources. The category of “on-site””contingency resources has been

added—thereby avoiding some of the old simplifications, and providing people in the

field more control.
Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization 57

Tom Iraci [July 2002] Photos USDA Forest

Service

New

Forest

Returns

Aspen trees

return to

Santa Fe

National

Forest

lands two

years after

the 2000

Cerro

Grande

Fire.

New

Homes

Rebuilt

New homes

reappear where the

Cerro Grande Fire

burned through Los

Alamos.

B. How to Make More Sense of a Complex Event: Prescribed Fire Escape

A different example is the fact that with your current categories, a fire is either within

prescription or it has escaped. To refine that distinction, you might want to think about

varieties of escape. Rather than a fire being either in prescription or escaped, maybe there

are times when it is both within prescription and escaped, and times when it is neither in

prescription or escaped.

Think about whether there might be times when what you are seeing might actually fit

these odd descriptions. When you do that, you are practicing a reluctance to simplify.

Once you begin to use a more detailed and differentiated set of categories to label your

world: You may discover more options for action. You may discover a greater variety of

potential clues that can tip you off that a situation is beginning to deteriorate. You could

be in a better position to make sense of more complex events.
58 Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization

C. Beware of Mimicking Nature as a Potential ‘Blind Spot’

A different example of a potentially troublesome simplification is the idea that when

planning a burn, the intent is to “mimic nature.” Your mindset: if nature starts more fires

in spring than fall, then that’s when we should also ignite fires.

But that may be a simplification that is misleading.

Nature’s ways—as judged by fire return intervals—may be relatively insensitive to more

recent changes such as: global warming, drought, different forest composition due to

suppression, and landscapes interrupted by human structures.

Disclaimer: we are not trying to sound like fire ecologists. That’s your specialty, not ours.

But we are trying to sound like people who have studied how labels and categories can

produce blind spots. If you lump burn plans together and try to design all of them to

“mimic nature,” then you may blind yourself to some differences that could give you

more options—or headaches.

To be sensitive to operations means, in part, to

put your understanding of operations into

words. That was the central message of the

handout’s Slide 57 entitled “Explain

Yourself.”

To be sensitive to operations means to

first tell people:

• What you think we face;

• What you think we should do;

3. ‘A Sensitivity to Operations’—Not as Easy as It Looks

• Why you think that is what we should do;

• What we should keep our eye on because

if that changes it’s a whole new ballgame.

You then need to ask people:

• What is unclear;

• What you might have missed;

• What they think they may not be able

to do.

A. Speak Up to Discover What You’re Thinking

Sensitivity to operations means partly that you make sense of puzzling situations—but

you do so publicly. When you explain your understanding of what you face, that gives

listeners a framework.

Equally important, you also hear yourself talk and you may discover that parts of your

reasoning are shakier than you realized.

A sizeable chunk of our life is spent living by the recipe: “How can I know what I think

until I see what I say.” People who live in the world of fire are no different. You have to

speak up to discover what you’re thinking. And then be prepared to update and modify

what you discover.
Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization 59

B. Beware of Your Relationship with Your Burn Plans

Sensitivity to operations means getting the big picture of what is going on here and now.

It’s important to keep this in mind because you tend to pay lots and lots of attention to your

burn plans.

On pages 42-44 in Managing the Unexpected, several liabilities of planning are noted,

especially the fact that plans tempt you “to search narrowly for confirmation that the plan

is correct.” The problem is, you overlook signs that the plan isn’t working and

unexpected events are piling up.

When people are sensitive to operations that are unfolding here and now, they catch the

unexpected sooner and, thus, are in a better position to deal with it.

There seemed to be sensitivity to operations during the prescribed fire up on Cerro

Grande. But that same sensitivity did not seem to continue on through the system until

it was too late.

C. Sensitivity to Operations Needs to Spread from Bottom Up to Top

Usually, when people hear the phrase “the big picture,” they think it refers to toplevel

stuff like strategy, system, plans, policy, a macro point-of-view. The good High

Reliability Organizations are teaching us that it’s just as important to have the big picture

at the bottom—where the situation is unfolding right here and now in all its intricacy.

NASA lost sight of the situation in the Columbia shuttle disaster when the organization

paid more attention to future shuttle flights than to the puzzling debris strike on the left

wing—caught on a fuzzy photograph.

Sensitivity to operations is an issue involving the frontlines in the field. But, the point of

this principle is that this frontline sensitivity has to spread upward in the organization—

not get stalled in a dispatch center that is insensitive to operations.

It’s interesting to us that when you looked for

examples of a commitment to resilience, the

example that you mentioned most often was

the After Action Review. The AAR seems to

be a program you like and a program that is

working.

But, even so, we would argue that the AAR is

4. ‘A Commitment to Resilience’—Your AARs Might Be Promoting

The Wrong Thing

an example of your efforts to intensify your

“Preoccupation with Failure,” and not so

much an example of resilience.

The AAR is an example of resilience only if

the lessons you learn from the AAR help you

increase your capabilities to deal with

unexpected events in the future.
60 Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization

Resilience is about making do with the

resources you have at hand to contain and

manage an unexpected event. And a

commitment to resilience is about increasing

the capabilities of those resources that you

have at hand so that they can better handle

whatever is thrown at them.

A. Resilience is Really Improvising to Better Deal with the Unexpected

Another word for ‘resilience’ is ‘improvisation.’ You do improvisation all the time. And

you’re good at it. You have to be. As one person put it during the workshop: “On every

fire we do have an idea what will happen, but what actually occurs is always a surprise.”

Paul Gleason didn’t plan to be a temporary burn boss, he actually had tickets to fly back

out of Albuquerque that day. Mike Powell didn’t anticipate that he would have to send

a newly arrived crew back down the hill for rest. No one expected that a much-needed

helicopter would arrive with no bucket.

Despite these setbacks and unanticipated events, people had to keep going. And that’s

where a commitment to resilience comes in. The broader and deeper the capabilities in

the group, the better your chances that they can re-plan and improvise a new system and

a new response that can deal with the unexpected.

B. ‘Before Action Reviews’ and’‘During Action Reviews’

In many ways, commitment to resilience takes the form of what might be called:

• A Before Action Review (Do we have lots of capability and do we have

confidence in our ability to recombine some of those capabilities in novel ways?);

• And a During Action Review (I didn’t expect this, but if we redeploy our people

we can handle it).

C. Our Investments in Our Burn Plans Can be Hazardous

An interesting tension in many of your discussions revolved around the fact that people

develop a big investment in the burn plan. This makes it harder for them to see the

necessity for improvisation when the unexpected occurs.

Furthermore, a big investment in a plan makes it even harder for a planner to accept that

having a capability for improvisation is a significant basis on which to select the people

who will manage the incident.
Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization 61

Several interesting themes surfaced in your

discussions of expertise. One of Wednesday’s

facilitated discussion groups said it was

important to “Defer to experience.” That’s not

quite the same thing as “Defer to Expertise.”

5. ‘A Deference to Expertise’’––‘Expertise’ Doesn’t Equate to

Experience

A person could have lots of experience with

fire, but not much expertise. This person could

keep showing up at fires, but never reflect,

seek feedback, experiment, learn, or try to

improve.

A. Experts Can Overestimate How Much They Know

Expertise itself can be something of a trap as in the fallacy of centrality notion (Slide 53

in the handout). Experts sometimes overestimate how much in-the-know they are. These

people can erroneously assume that if something threatening or unexpected or potentially

dangerous were occurring, they would know about it. Thus, if they don’t know about it—

then it isn’t occurring.

When experts think this way, the people who work with them are ill-prepared to deal with

growing problems until it is too late. As Kathie Sutcliffe has found in her research in

medical settings, the fallacy of centrality discourages curiosity.

B. It is Everyone’s Responsibility to Communicate Warning Signals

But expertise can be something of a trap for the consumer of expertise as well as the

expert. We saw a good example of this in the Tenerife air disaster (studied on Monday).

The KLM pilot was head of training at KLM and his co-pilot had been trained by this pilot.

When the co-pilot sensed that the premature takeoff of the KLM plane might be in error,

he did not speak up to the pilot. Instead, he assumed that if another plane was on the

runway ahead, surely a pilot of this stature would know it.

Similar dynamics may be put in play when there are big differences in expertise on fire

management teams. People with lesser expertise may spot early warning signals but fail

to mention them under the assumption that—if they were really significant—the expert

would say something about them. But since he or she is saying nothing, there must be

nothing to worry about.

In this case, no news is not good news. No news means simply: no news. And it is

everyone’s responsibility to communicate whatever news they do know and not to

assume that it is common knowledge.
62 Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization

Paul Gleason described your situation as one

of “limited information in a dynamic

environment.” You could also say your

situation is: unpredictable, often ambiguous,

and usually complex.

So?

So, because you don’t face clearcut questions

to which there are clearcut answers, more and

more data won’t help you that much.

Instead, you’ve got to hammer-out some sense

of what seems to be happening, and then

update that sense often and through

discussion. That’s why we kept urging that

you see yourselves NOT just as

decision-makers, but as “sensemakers.”

NASA did not do a good job of sensemaking

in the Columbia disaster. Why? Because they

used inappropriate models and ignored cues

of trouble from both the shuttle as well as the

administrative hierarchy in Houston. And

because they did a poor job of prior

sensemaking, when they finally got around to

Karl Weick’s Key Principles to Emphasize

making decisions (e.g. Should we try to get

external photographs of the damage?), they

made bad decisions.

But the problem wasn’t with their decisionmaking. It was with their sensemaking. It was

their tendency to look for data that confirmed

their belief (and hope) that things were okay

on the shuttle—their tendency to see this as an

“in-family” event that they already knew about.

Both of these tendencies set the stage for the

wrong decision. The remedy lies in:

• Candor;

• Trustworthy reporting;

• Listening;

• Actively seeking viewpoints;

• A willingness to negotiate a workable

understanding of what might occur;

• And how to deal with the inevitable

gaps that will show up inside that

understanding.

At Edward Hiatt’s Staff Ride stand, he was

still amazed that a one-inch wide finger of fire

crawled across the black, ignited a stand of

one-foot tall bunch grass that would relight

every time he thought he had it extinguished.

Thus, this slop-over became harder and harder

to catch.

2. Small Stuff Makes All the Difference

1. You Don’t Need More Data

Cerro Grande is a story of other small stuff

like a depleted Black Mesa crew, a prescribed

burn not entered in the dispatch log, a

temporary dispatcher on duty at night, a new

FMO in the adjacent Santa Fe National

Forest, water drops from a small bucket at

10,000 feet, a Haines Index of 6.
Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization 63

These are small events with large

consequences. High Reliability Organizations

have learned the significance of the small

stuff. Mindfulness incorporates a deep

respect for the small stuff and what it can

become.

If there is one flaw with the phrase “High

Reliability Organization,” it is that these three

words are too static.

We’d all be better off if we kept referring to

High Reliability Organizing.

Systems, teams, groups, and the best laid

plans all unravel. You have to keep redoing

them. Al King and Mike Powell were

continually reorganizing the burn crew.

While it is true that you may want to develop

mindfulness as a standard operating

procedure, this doesn’t mean you run through

the routine mindlessly. It means that you audit

your group often to see where your strengths

and weaknesses are. (See Chapter 4 in

Managing the Unexpected.)

While you may not realize it, you’re probably

already doing something about all five of

these High Reliability Organizing properties.

Yet, until you actually do realize this, you

can’t improve and strengthen how you’re

doing it.

High Reliability Organizations try to tilt the

playing field of risk to better enable the ability

to spot events that are hard to diagnose—but

easy to cure. They do so because they know

full well that by the time those events become

easy to diagnose, they are much, much harder

to cure.

3. Reliability is Not Bankable

This means you use the five High Reliability

Organizing properties as a checklist, as a

briefing format, as a set of “watch outs” for

reliable team functioning.

Organizing for High Reliability means fitting

the High Reliability principles with

guidelines that you know well and value. For

example, think about the fit between LCES

and the five High Reliability Organizing

characteristics:

Lookouts are people whose role is to be

sensitive to operations and to be preoccupied

with expectations for fire behavior that fail.

Communication covers all five High

Reliability Organizing characteristics, but is

geared to be sure that sensemaking and

decision-making flow toward expertise, and

that people are not oversimplifying but rather

are attentive to fine-grained details that signal

changing conditions. Escape routes and

Safety zones are the epitome of both

resilience and a preoccupation with failure.

Escape routes and safety zones also represent

capabilities that allow crews to bounce back.

Karl Weick
64 Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization

We all know the scenario.

You go to a stimulating conference or workshop. You become motivated and inspired. You can’t

wait to get home and apply your new insights, your new enthusiasm.

But once you’re back in your regular home office routine, your newly acquired motivation,

inspiration, and good intentions unintentionally get relegated to some distant mental back burner.

Like the best of our New Years resolutions, no change ever really occurs.

“It seems that at even the best of conferences, people get very pumped up. But they don’t have

that same energy level when they return home,” organizational psychologist Lisa Lahey tells the

Managing the Unexpected Workshop audience—mostly prescribed fire people primed with

three full days of Managing the Unexpected ideas and stimuli. “We want to show you how you

can increase the likelihood that you can find a way to take this energy back with you.”

“We want to provide you a seamless transition on what you’ve been doing this week to when you

return home,” confirms fellow organizational psychologist Robert Kegan.

VIII Day Four: Immunities to Change

A Facilitated “How-To” Commitment Exercise

Presented By Robert Kegan and Lisa Lahey

“Robert Kegan and Lisa Lahey’s research tells us that change

doesn’t come naturally. In planning this workshop, we realized that

most of the commitments we would make during our week in

Santa Fe would probably disappear and not be acted on. That’s

why we decided to conclude the workshop with these two

nationally recognized organizational psychologists. Their

facilitated exercise will help us understand why there’s a natural

immunity to change in all of us. They’ll give us hands-on methods

for overcoming this resistance. And they’ll be following up with

participants to see if we make any progress.”

Dave Thomas, Chair

Managing the Unexpected Workshop
Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization 65

“The wildland firefighting community lives a repeating story. Sooner or later,

disaster strikes and firefighters lose their lives in the line of duty. An

investigation follows; causes are determined and remedies suggested. For a

time, there is increasing vigilance for safe operations, but the vigilance declines

over time. At some point, disaster strikes again and firefighters lose their lives.

The question arises, does anything ever really change?

Do we ever really learn anything?

. . . Rather than aiming for the immediate relief of symptoms or for behavioral

strategies to bring about short-term solutions, the authors [Kegan and Lahey]

focus on the deeper, underlying changes in the way individuals and groups

make meaning. The book is for people interested in the possibility of their own

transformational learning, as well as for people interested in supporting the

transformational learning of others—an increasingly necessary feature of

effective leadership.”

Jim Saveland, Workshop Co-Chair

Assistant Director for Research, Rocky Mountain Research Station

From his review of Kegan and Lahey’s book How the Way We Talk Can Change the

Way We Work that appeared in the Fall 2002 Fire Management Today Vol. 62, No. 4

Tom Iraci Photo USDA Forest Service

Robert Kegan (and Lisa Lahey behind him on right in blue) help the workshop participants

explore and negotiate their sometimes challenging Immunities to Change exercise—which

includes responding to the four self-reflective bulleted items above.

Self-Reflection Proposed to Workshop Participants

• What’s your biggest contribution to becoming a High Reliability Organization?

• If the people closest to you at your home unit could tell you the four things you need to focus

and improve on, what would they be?

• What’s the highest priority change you’d like to see occur when you get home?

• Take a fearless inventory of all the things you do or fail to do that work against your

High Reliability Organization commitment.
66 Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization

Lisa Lahey, who observed the

previous day’s facilitated workshop

conclusion, said she was “impressed

and moved by the energy and

enthusiasm” she witnessed.

How To: Uncover Your Inexplicable Resistance to Change and

Your Subconscious Goals

Robert Kegan is the William and Miriam Meehan

Professor of Adult Learning and Professional

Development and Lisa Lahey is the Research

Director of the Change Leadership Group at the

Harvard University Graduate School.

Co-authors of How the Way We Talk Can

Change the Way We Work, they are also the

founding principals of Minds at Work

(www.mindsatwork.com), a Massachusetts-based

consulting firm.

They not only provided the Managing the

Unexpected Workshop participants their hands-on

“Immunities to Change” facilitated exercise, they

also provided an ongoing follow-up effort.

Twenty workshop attendees participated in this

three-month follow-up “coaching process.”

From Kegan and Lahey’s The Real Reason People Won’t Change

Harvard Business Review article:

Although competing commitments and big assumptions tend to

be deeply personal, groups are just as susceptible as

individuals to the dynamics of immunity to change.

Face-to-face teams, departments, and even companies as a

whole can fall prey to inner contradictions that ‘protect’ them

from significant changes they may genuinely strive for . . .

Overcoming immunity to change starts with uncovering

competing commitments. In our work, we’ve found that even

though people keep their competing commitments well hidden,

you can draw them out by asking a series of questions—as long

as employees believe that personal and potentially

embarrassing disclosures won’t be used inappropriately.

It can be very powerful to guide people through this diagnostic

exercise in a group . . .
Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization 67

“The goal of this follow-up process is for each

person to overturn his or her personal

immunity to change in order to change

behaviors and thinking patterns,” explained

Lisa Lahey. “In this way, the person can

maximize his or her inherent capacities and

more fully realize those changes he or she is

committed to toward developing High

Reliability Organizing skills.”

Lahey said the basic ingredients of this

follow-up process include:

• A series of structured “learning

opportunities” (assignments).

• Coaching conference calls.

• Baseline performance data.

• Post-coaching data collected for each

individual.

• On-going dialogue on the coaching

platform.

• Aligning personal commitment and

organizational objectives.

“In general,” Lahey reported eight weeks

after the actual conference, “people have

If there are 7 frogs on a log and 5 decide to jump off into the water, how many

frogs are left on the log?

If you answered 2, Robert Kegan will tell you—just as he informed the

Managing the Unexpected Workshop participants—you are wrong.

If there are 7 frogs on a log and 5 decide to jump off into the water, there are still

7 frogs left on the log.

“Simply deciding to do something—is not doing it,” Kegan enlightens.

He and Lisa Lahey’s unique Immunities to Change exercise is designed to teach

people how to overcome their barriers and limitations. To go beyond simply

deciding and intending to do something. To actually do it.

To change.

20 Workshop Participants Join Three-Month Follow-up Coaching Process

clarified and tightened-up their immunity

‘maps’ so that they best capture competing

commitments and are delving deeper into the

‘Big Assumptions’ that ground their

immunity systems.”

She said that many participants had also

aligned their personal commitments for change

with HRO objectives and their own work

goals and objectives. In addition, by early

July, a few people had already begun their

important “baseline data collection.”

Next Step Might Appear

‘Small’; But It’s Not

Lahey said the next step is becoming aware of

your competing commitments by moving the

“immune system” from unconscious to

conscious. “We will be asking people to

engage in systematic observation of their

assumptions in action. While this may appear

to be a small step, it’s not.”

She said this oft-times most difficult step

involves observation—not action.
68 Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization

“Often, conscientious people want to move

quickly from awareness into action. But for

significant challenges, that’s an uncharitable

expectation to have of oneself,” Lahey assures.

After this stage is achieved, she explains that

“It’s not about identifying unproductive behavior . . . It’s not

about coaxing or cajoling or even giving poor performance

reviews. It’s about understanding the complexities of people’s

behavior, guiding them through a productive process . . . And

helping them cope with the inner conflict that is preventing

them from achieving their goals.”

The Real Reason People Won’t Change

Harvard Business Review

By Robert Kegan and Lisa Lahey

“It’s a psychological dynamic called a ‘competing

commitment.’ And until managers understand how it works and

the ways to overcome it, they can’t do a thing about

change-resistant employees.

Harvard Business Review, November 2001

“people will begin to design safe and modest

tests of their assumptions so that they can

mindfully discover the situations in which those

assumptions may be legitimate—and, just as

importantly, the situations in which they are

not valid.”
Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization 69

When I look back at the

entire Managing the

Unexpected Workshop,

several important topics come to mind.

First and foremost is this workshop’s Staff

Ride. I have been on a couple of these now.

They amaze me.

As discussed in Chapter V, four courageous

individuals returned to the site of the “Cerro

IX Conclusion – We Have Lit a Match and

Started a Fire

Our world of fire management is fraught with low probability, high

consequence events. There’s always a slim chance that something

terrible is going to happen. And when it does, it is truly terrible.

Our job entails the use of fire to restore and maintain healthy

ecosystems and to protect human communities and what they value.

Managing one of the most powerful forces in nature is challenging. On

occasion, disaster does strike. A major escaped fire can result in the loss

of: life, valuable property, critical infrastructure (drinking water

supplies, power grid), and cherished natural resources.

We ask ourselves: “Are there weak signals of impending doom? If we

pay close enough attention to these signals, will we be able to make

sense of the situation with enough time to take action to avert disaster?”

This workshop was about bringing the latest social science to the

management community in an effort to enhance our individual and

collective sensemaking ability and our ability to change things for the

better. The central question we examined: What does it mean to be

constantly organizing for high reliability? And—like the last question in

an After Action Review—what do we need to keep doing and what

things do we need to do differently in our day-to-day operations?

Jim Saveland

We Have Lit a Match and Started a Fire

By Jim Saveland

Workshop Co-Chair

Assistant Director for Research,

Rocky Mountain Research Station

Grande” prescribed fire to make our Staff

Ride a success.

This unique undertaking enabled us to look

beyond the investigations and begin to make

sense of what happened (with this prescribed

fire) for ourselves.

Making sense of the situation retrospectively

improves our ability to make sense of similar

situations in the present moment—

aka mindfulness.
70 Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization

I am reminded of Jerry Harvey’s classic book

The Abilene Paradox and Other Meditations

on Management. The Abilene Paradox

chapter explores how groups take collective

actions contrary to the desires of any of their

individual members.

Elsewhere in the book, Harvey makes the

impassioned plea that we desperately need to

develop organizational policies, procedures,

and processes that facilitate forgiveness and

grace:

“In fact, cautious inactivity occurs

in virtually all formal organizations,

because we generally have no

processes, procedures, or policies

for granting forgiveness. This is

particularly unfortunate, since the

ancillary effects of grace are risk

taking, innovation, reality testing,

and community building.”

With this Staff Ride we facilitated

forgiveness and grace. And, because of this,

we are much richer.

Harvey also writes of “The Gunsmoke

Phenomenon” in which leadership stands up

to angry lynch mobs. Jim Collins in his

extensively researched book Good to Great

makes a similar point about the leadership

required to transform a good company into a

great one:

“Leadership is equally about

creating a climate where truth is

heard and the brutal facts confronted.

How do you create a climate where

the truth is heard?”

Collins offers four basic practices, including:

“Conduct autopsies—without blame.”

We Have Searched

For Someone to Blame

Whether investigating fatalities or escaped

prescribed fires, we have not stood up to angry

lynch mobs in the past. Rather, we have

searched for someone to blame.

We can and must do better.

I am sick and tired of the phrase “hold people

accountable” as a euphemism for finding

someone to blame and inflicting punishment.

We need to hold systems accountable and

trust people.

“ . . . We must be more willing to seek peer reviews and to seek input from the outside.

We must focus more on situational analysis—so we’ll have a less likely chance of being

unexpected . . .”

“We need to get all the documentation out on the Cerro Grande Staff Ride . . .”

“We also need to be resilient. We need to lead the way. We have the background and we

learned the tools this week. We need to move from decision-making to sensemaking—

and, in the process, we need to be mindful . . .”

Dick Bahr, Workshop Co-Chair

Fire Use Specialist, Fire Program Center

National Park Service
Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization 71

The only person I hold accountable is myself.

Jim Collins calls this “Level 5 leadership:”

“Level 5 leadership looks in the

mirror, not out the window, to

apportion responsibility for poor

results, never blaming other people,

external factors or bad luck. [It] looks

out the window, not in the mirror, to

apportion credit for the success of the

company – to other people, external

factors, and good luck.”

Valuable Feedback

Karl Weick and Kathleen Sutcliffe’s

follow-up commentary (Chapter VII) is

valuable feedback. This is not easy material.

It will take several iterations to “get it right.”

I would like to echo some of the important

points they make:

• High reliability systems make strong

responses to weak signals.

• Labels and categories can produce blind

spots.

• The importance of improvisation.

• The need to improve sensemaking.

Meaningful Personal Development

In Robert Kegan and Lisa Lahey’s “Immunity

to Change” exercise, I reflect on my “Big

Assumptions.” And, when I find the courage,

I test them. I am convinced that this exercise

is an effective way to create meaningful change

that enhances our personal development.

Importance of Sensemaking

Weick and Sutcliffe have shown the

importance and central role that sensemaking

plays in high-performing individuals and

organizations. Our ability to make sense in the

moment is “mindfulness”.

Kegan developed a theory of adult

development based on how we make meaning

(sense). Our sensemaking ability changes over

time as we develop. Kegan and Lahey

developed their Immunity to Change exercise

to help us make substantive change and to

navigate our personal development.

Create an Environment

that Fosters Growth

and Development

If we are truly interested in high performance,

we need to abandon anachronistic

“performance management” strategies aimed

at coercing compliance.

“ . . . From the research community, we want to partner with you to get fire on the

ground . . . We also want to continue to partner with universities.”

Anne E. Black, Workshop Participant

Post Doctoral Research Ecologist

Aldo Leopold Wilderness Research Institute
72 Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization

Rather, we need to focus on creating an

environment that fosters our growth and

development.

With this workshop we have lit a match

After Action Reviews

At the last day’s conclusion, an After Action Review of the entire workshop—involving

all of the participants—was conducted by Michael DeGrosky. (DeGrosky led a similar

After Action Review with his facilitators the previous day.)

On Friday morning, DeGrosky facilitated the final After Action Review with the

workshop’s steering committee members. Information from all of these reviews will be

used to hone and enhance any future Managing the Unexpected workshops.

and ignited a fire. Hopefully the fuel bed

and environment is ripe for these ideas

and practices to spread through our

organizations.
Managing the Unexpected in Prescribed Fire and Fire Use Operations – A Workshop on the High Reliability Organization 73

Dave Thomas, Chair

Regional Fuels Specialist, Intermountain Region, USDA Forest Service

Dick Bahr, Co-Chair

Fire Use Specialist, Fire Program Center, National Park Service

Jim Saveland, Co-Chair

Assistant Director for Research, Rocky Mountain Research Station

Paula Nasiatka

Manager, Wildland Fire Lessons Learned Center

Wayne Cook

Fire Use and Technology Transfer Specialist, Missoula Fire Sciences Laboratory

Linda Langner

Research and Development, Washington Office, USDA Forest Service

Representing National Wildfire Coordinating Group Social Science Task Group

Paula Seamon

Director of Fire Management and Training

The Nature Conservancy’s Fire Initiative

Tim Sexton

Fire Use Program Manager, USDA Forest Service

Michael DeGrosky

Lead Facilitator, Chief Executive Officer of The Guidance Group

June Genf

Support Services to Workshop, Intermountain Region, USDA Forest Service

Dick Mangan

Lead Workshop Organizer, Blackbull Wildfire Services

Joette Borzik

National Fire Training and Qualifications Specialist

U.S. Fish and Wildlife Service

Paul Keller

Lead Writer-Editor

X Steering Committee Members
Mindfulness . . .

Paying attention—individually and organizationally—in different ways . . .

Learning how to struggle for a new alertness . . .

Our preoccupation with failure . . .

How the architecture of simplicity can get us into trouble . . .

Rather than relying on “experts,” letting decisions migrate to those

with the proper expertise to make them . . .

These are some of the concepts into which the Managing the Unexpected

Workshop participants were immersed—in a quest to integrate the High

Reliability Organizing ideas and characteristics into their future work—at

both the local and national levels in the prescribed fire and fire use arena.

The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs

and activities on the basis of race, color, national origin, sex, religion, age, disability, political

benefits, sexual orientation, or marital or family status. (Not all prohibited bases apply to all

programs.) Persons with disabilities who require alternative means for communication of

program information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET

Center at (202) 720-2600 (voice and TDD).

To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, Room

326-W, Whitten Building, 1400 Independence Avenue, SW, Washington, DC 20250-9410 or

call (202) 720-5946 (voice or TDD). USDA is an equal opportunity provider and employer.

A video and DVD production highlighting the entire four-day May

2004 Managing the Unexpected Workshop is in production and

will be available through the Wildland Fire

Lessons Learned Center.