# H I G H 

# R E L I A B I L I T Y 

# O R G A N I Z I N G

What It Is, Why It Works, How to Lead It

Sponsored by the

Fire and Aviation Directorate

Division of Fire Operations

March 9

- 11, 2010 BLM National Training Center
Phoenix, AZ

## A B S T R A C T

In March, 2010, the BLM Fire and Aviation Directorate’s Division of Fire Operations hosted a

three

- day training session on h igh r eliability o rganizing (HRO). Participating in this training were national, state, and unit level fire managers from throughout the BLM

— almost the entire senior leadership in the BLM f ire p rogram.

The intent of the training was to es tablish a common understanding of h igh r eliability o rganizing and to build an initial foundation for implementing high reliability practices throughout the BLM

f ire p rogram. At the conclusion of the session, each state identified initial actions they would

take in their effort to establish HROs in their programs.

Based on positive feedback from the session and a common desire among all BLM fire leaders to excel in all areas of fire operations and risk management, follow

- up actions are planned.

Actions include reports from states on their suc cesses after the 2010 fire season and,

tentativel y, a follow

- up to this HRO training session in the near future.

This publication is intended to summarize the high points of the training session and to informally document the initial planned actions of BLM fire managers toward implementing HRO practices.1 

## B L M D I R E C T O R 

## B O B 

## A B B E Y 

## ’ S 

## O P E N I N G 

## R E M A R K S

( Video Message Excerpts )

Good m orning. I’m pleased to kick off BLM’s fire management conference focusing on h igh r eliability o rganizations. My purpose today

is two

- fold. First, to offer my views about fire and aviation and where the program needs to head; and second, express my s trong s upport for making BLM a h igh r eliability o rganization particularly in fire and aviation where the risk is high and the work is crucial to protect life, property, and vital natural resources.

Although the 2009 fire season was light in most of the West...hist ory shows us that widespread and severe wildland fire activity will return. We cannot afford to be complacent. When things go right for a long period of time, it’s all the more signal that we need to be more aware, more prepared, more able to respond appr opriately to whatever the situation demands. Nothing affects our resources faster for both good and ill than

does fire.

As you position the fire program for the future, you face a number of difficult but doable tasks related to further integrating fire an d resource management

— achieving and communicating steps underway to accomplish new fire policy implementation strategies, continuing your cost management efforts, and more. I am confident, however, that you have the knowledge and experience to manage these challenges in a positive manner.

Fire and Aviation is the largest single program in the Bureau of Land Management and one of the most visible. Because of that, I expect nothing but the highest standards of integrity, conduct, and performance.

So, your c hallenge is clear as leaders in the fire program

— you must keep one eye on the present and one eye on the future and take the steps now to recruit, train, and retain a new generation of capable and qualified fire and aviation managers and leaders. If we do not act now, the future may be bleak.

Let me say right at the top, I’m a firm believer in HRO principles; and I believe they need to be adopted and practiced throughout our agency. Safety is of critical importance in every area of BLM fire operations. How ever, wildland firefighting is an inherently dangerous undertaking.

The “Red B ook ” states, “Our safety philosophy acknowledges that while the ideal level of risk may be zero, a hazard

- free work environment is not a reasonable or achievable goal in fire

op erations.” For this reason, we’re never satisfied. We are driven to improve. Even when we perform exceptionally well for long periods of time, we are uneasy. We know a mistake, an oversight, or a short lapse of attention might just be around the corner. We know we can do better. These very characteristics, our constant drive to improve, our refusal to be complacent, our perpetual uneasiness even when things are going well, our ability to recover quickly are characteristics common to h igh r eliability o rganiz ations. This conference on HROs is part of our unending effort to improve. Thank you for being here.

Finally, I hope you leave this conference with a better understanding of h igh r eliability

o rganization theory

... and of its relationship with various other o rganizational concepts, ideas, and practices. Most importantly, I hope you leave with an idea of how you might develop or improve HRO practices in your organization. Then my expectation is that you will go home; and armed with what you’ve learned this week , you will begin to make the needed changes in your area of responsibility. Please know that you have my support and backing.

(The complete transcript can be found at: ht tp://www.blm.gov/nifc/st/en/prog/fire/training/fire_training/hro.html ) “We cannot afford to

be complacent.”2 

## I N T R O D U C T I O N

The intent of this training was to help BLM fire managers build highly reliable wildland fire organizations at the national, state and

district levels.

The training was conducted in workshop format with various speakers sharing knowledge and implementation ideas.

Donna Hunter and Dave Thomas facilitated

the training session , providing their expertise on h igh r eliability o rganizing

. Jim Saveland appeared as a guest s peaker on

communications.



## J IM 

## D OUGLAS



### F IRE AND 

### A VIATION



### , A SSISTANT 

### D IRECTOR

 “ The future of BLM fire is tied up with the Quadrennial Fire Review (QFR). “The QFR

is our north star.”

 “IFPM requires us to maintain a well trained and qualified workforce.”

 “Be leaders, set standards, and lead by example. Push these HRO principles into your organizations.”



## T IM 

## M URPHY



### F IRE AND 

### A VIATION



### , D EPUTY 

### A SSISTANT 

### D IRECTOR

 “It has been 10 years since the State and Unit level Fire Management Officers (FMOs) have assembled together with National Fire Program Leaders. In that

time

, the BLM has seen many

successes and a few failures. We know there are no such things as close

calls...these are lessons.”

 “We must continue to promote and

adhere to the principles of h igh r eliabil ity

o rganizing.”

 “This conference is a fundamental step in improving our capabilities.”

“ How well are we prepared to deal with the unexpected?” ~ Tim Murphy D ave Thomas (left), Jim Saveland (middle), Donna Hunter (right)3 

## H R O

~ W H A T 

## I T 

## I S

In 1984, a group of University of California

researchers studied operations and organizational culture in three organizations : the air traffic control system, a nuclear power plant, and U.S. Navy aircraft carriers. Their intent, broadly, was to determine why some organizations that routinely operate in high risk

enviro nments endure less than their fair share of

accidents.

The term “ h igh r eliability o rganization” (HRO)

came from this research. Little hard data exists to quantify HROs, but researchers have broadly defined them, and they have described HRO qualities and c haracteristics. These descriptions may prove useful to organizations that are attempting to model practices and achieve results of high reliability organizations.



## D EFINITIONS OF A 

## H IGH 

## R ELIABILITY 

## O RGANIZATION

 An organization that operates continuously und er trying conditions and has fewer than its fair share of major incidents. ( Karl E. Weick and Kathleen M. Sutcliffe)

 An organization that has succeeded in avoiding catastrophes in an environment where normal accidents can be expected due to risk factors an d complexity. (Wikipedia)



## C HARACTERISTICS OF 

## HRO S

 Preoccupation with failure.

 Reluctance to over simplify.

 Sensitivity to operations.

 Deference to expertise.

 Commitment to resilience.



## HRO IN 

## BLM F IRE 

## O PERATIONS

There are a number of concepts, systems, methods, and models that can be used by an organi zation in its pursuit of a safety culture. Many are useful, and most are complementary to one another. HRO theory is one

of them. Goal #5 of the BLM F ire and Aviation Strategic

Plan is to develop a high r eliability o rganization. Toward this end, BLM fire p ersonnel are encouraged to study HRO characteristics, or any other constructive safety practice, and apply them to their own units. 

### B L M F i r e & A v i a t i o n S t r a t e g y P l a n G o a l # 5 ~ A H i g h R e l i a b i l i t y F i r e

a n d A v i a t i o n O r g a n i z a t i o n ( H R O )

O BJECTIVES

1. Have a fire culture and processes that reduce system errors.

2. When failures occur responses are

effective and resilient.

3. Have fire and aviation leaders that understand and promote HRO principles.

4. Have a reward system in place that supports HRO principles.

5. Have all employees understand that
safety is the priority BLM fire

management objective.4 

## H R O

~ W H Y 

## I T 

## W O R K S

Karl Weick and Kathleen Sutcliffe cite wildland firefighting crews as one ex a mple of a h igh

r eliability o rganization in their book, Managing The Unexpected

– Resilient Performance in an Age of Uncertainty. They ask their readers to use our organization as a benchmark, “not because they ‘have it right’ but because they struggle to get it right on a continuous basis.”



## HRO: A D ISCIPLINE OR A 

## R ECIPE 

## ?

Donna Hunter explained to attendees that HRO s are developed more through discipline than following a recipe for success.

The goal of HRO is to have employees operate in a hyper

- vigilant state of mind. Hyper

- vigilant employees

“ r ecognize even subtle signals , and k now that the signal was significant in cont e xt. ”

Quoting Karlene Roberts in New Challenges to Understanding Organizations, Hunter noted that employees in HRO s :

1. Seek perfection but never expect to achieve it

. 2. Demand comple te safety but never expect it

. 3. Dread surp rise but always anticipate it.

4. Deliver reliabilit y but never take it for granted

. 5. Live by the book but are unwilling to die by it.

The four key pillars for sustainable risk management taken from James Reason’s Managing the Risks of Organizational Accidents are :

 Reporting Culture

~ Safety cultures are dependent on knowledge gained from near
misses, mis takes

, and ot her “free lessons.” P eople must feel willing to discuss their own

errors in an open, non

- punitive environment

.

 Just Culture

~ An atmosphere of trust where people are encouraged to provide

essential safety

- related information yet a clear line is drawn between acceptable and unacceptable behavior.

 Flexible Culture

~ One that adapts to changing demands by flattening hierarchies and deferring to expertise regardless of rank.

 Learning Culture

~ The combination of candid reporting, justice, and fl exibility enables people to witness best practices and learn from ongoing hazard identification and new ways to cope with them.

To be a premier organization we must:

**•** Feed the l earning back into the organizations

**•** Encourage team members to as k critical ques tions. “Vigilance is the price you pay for safety.”

~ Donna Hunter5 

## HRO

~ T HE 

## F IVE 

## B ASICS 

## P RINCIPLES



### D AVE 

### T HOMAS AND 

### D ONNA 

### H UNTER



### 1. **P REOCCUPATION WITH**  

### F **AILURE**

 Vigilant attention to e arly detection of small errors

.  Encourage reporting of errors and near misses.

 We should be worried we haven’t caught everything...we worry when things are going too smoothly...w e realize that any lapse is a symptom that something could be wrong with the system.

 We tend to look at large errors with catastrophic consequences but we should look for small failures to avoid large errors. We should be pre occupied with failure before an

event occurs

.  We should look at fatality incidents starting months before the accident and ask ourselves, “ W hy did everything they did make sense to them at the time?”



### 2. **R ELUCTANCE TO**  

### O **VER** 

### S **IMPLIFY**

 This is not the KISS (Keep It Simple and Short ) theory. While checklist and s tandard

o perating p rocedures (SOPs) help us stay focused on key issues and indicators, we

know that to manage for t he unexpected, we should be reluctant to accept over

simplification.

 We must ov ercome the tendency to simplify by inviting skepticism to conventional

wisdom

, questioning standard procedures , and reconciling diverse opinions

.



### 3. **S ENSITIVITY TO**  

### O **PERATIONS**

 Even small variations in operations deserve individual attention.

 A vigila nt eye on operations helps us make continuous adjustments that prevent s mall

errors now before they become large errors in the future

.  We must notice anomalies while they are still tractable and can be isolated . They need to be caught before they escalate in to a catastrophic accident.

 Most accidents are not the result of a single error, but rather an accumulation of numerous small errors that result in a disproportionately large accident.

“We look at our organization like an a ir t raffic c ontroller looking at a radar screen...looking for weak signals that just bleep on occasion. This is how we maintain an organizational preoccupation with failure and sensitivity to operations.” ~ Sheldon Wimmer, SFMO Utah “When they (HROs) ‘recognize’ an event as something they have experienced before and understood, that recognition is a source of concern rather than comfort. The concern is that superficial similarities between the present and the past mask deeper differe nces that could prove

fatal.” ~ Karl E. Weick “Checklists have their place so we shouldn’t throw them out because they are over simplified. Rather, we need to continually ask ourselves what we are missing in our over

- simplification.” ~ Michelle Ryerson, BLM Safety Manager6 

### 4. **D EFERENCE TO**  

### E **XPERTISE**

 HROs push decision making down to the front line (point of the spear), and authority migrates to the person with the most expertise, regardless of rank.

 Expertise is not confused with expe rience. Experience by itself does not guarantee expertise. We must scan up and down the chain of command to find the right expertise needed to handle the current or potential problem.

 Decision making should migrate to the person with the unique knowledge n eeded to confront the given situational complexities.



### 5. **C OMMITMENT TO**  

### R **ESILIENCE**

 HRO s have the ability to be stretched and still bounce back. They continuously evaluate the worst case scenario and pr actice internal fire drills.

 They know they haven’t seen all the ways that a system can fail.

 HROs cultivate employees to confront organizational obstacles and actively find

solutions or workarounds.

 HROs are vigilant at keeping errors small and improvising workarounds that allow the system to keep functioning.

“HROs put a premium on training, personnel with deep and varied experience, and skills of recombination and making do with whatever is at hand.” ~ Karl E. Weick and Kathleen M. Sutcliffe7 

## O RGANIZATIONAL 

## I NPUTS TO A 

## R ESILIENT 

## S YSTEM

The ability to deal with an emergency situation is dependent on the systems, structures, and cultures put in place before a crisis occurs. Resiliency includes both individual and organizational inputs. These inputs include:

 Knowledge gained through openness and sharing of information.

 Accumulated experience

.  Facilitated learning

.

**•** Maximize a reporting culture

.  Restructuring to meet demand of the organization not previously anticipat ed

.  Coping with unforeseen challenges

.  Flexibility and adaptability in available people and resources to mitigate challenges

.

**•** We need to have the right people with the right authority to make decisions in a timely matter.

**•** W e feel empowered to take drastic measures when necessary ; e.g., c losing down a major freeway during a wildfire or exercising the right to turn down an assignment

.



## H OW 

## D O 

## W E 

## M AINTAIN 

## R ESILIENCY 

## ?

 Sponsor leadership courses which

stress communications and the ability to speak up at all levels of the organization.

 Lead by example (s how quick deci sion making or play “ what if ” games )

.  Run premortem and p ost mortem

e xercises

.

**PREMORTEM EXERCISES**

Premortem exercises are very powerful tool s that begin by looking at an incident that will take place in the near future. All participants are instructed to assume that something went spectacularly wrong and are then asked to determine the cause of this tragic ending

, and identify ways of preventing this failure from happening . Premortem exercises:

 Can be done on a sche duled prescribed fire or in an i ncident a ction p lan (IAP).

 Let all participants introduce their idea of what went wrong. Supervisors invite

subordinates to tell them how this incident or plan can fail.

 Look for blind spots.

 Determine ways to prevent this failure.



### P **OSTMORTEM EXERCISES**

Postmortem exercises l ook at a past incident . Participants identify what happened and then analyze w hy it happen ed. Postmortem exercises :

 Are m or e in depth than an a fter a ction r eview (AAR) but not as detailed as an investigation.

 L ook at organizational systems months before the incident.

 Are designed to avoid hindsight bias.8 

## C OLORADO 

## ’ S 

## C OMMITMENT TO 

## R ESILIENCY



### K EN 

### K ERR

, C OLORADO S TATE FMO

Ken Kerr shared his thoughts on how his fire program in Colorado learned the hard way to

bounce back after a brutal audit of their

program.

He explained that although external audits can be brutal, they can also prove to be extremely valuable in maintaini ng a commitment to resiliency. They force you to look at your organization through a new set of eyes and see your operation differently. They also teach you how to deal with distractions, especially when they happen in the middle of a busy fire season.



## BL M S MOKEJUMPER 

## P ROGRAM

S EAN C ROSS

, BLM P REPAREDNESS /S UPPRESSION S TANDARDS C HIEF

AND H ECTOR M ADRID

, BLM B OISE S MOKEJUMPER C HIEF

Sean Cross and Hector Madrid talked about

the reviews that the BLM smokejumper program went through following the fatal parachut ing accident of Dave List o n in 2000 and the systemic changes made to the program after the incident. The BLM smokejumper operations were shut down

for almost three months while program reviews w ere conducted. The reviews confirmed many positive aspects of the smokejumper program and offered constructive suggestions for improvement.

Madrid explained the Boise Smokejumper s ’ Malfunction/Abnormality Reporting System (MARS) which was initiated after the Dave

List o n accident. The system was designed to encourage any employee to report what may

be considered even the most minor abnormality in smokejumper operations or the parachu ting system.

He explained that the idea was difficult for the crew to buy into at first as they thought it may lead to another shut down of operations. But over a number of years, the crew saw the benefits of reporting. Managers encouraged reporting by off ering time

- off awards as incentives. “The Boise smokejumpers continually look for ways to improve the program.” ~ Hector Madrid9 

## C OMMUNICATION 

## T OOLS



### J IM 

### S AVELAND

Effective communication is an importa nt component of

HRO s

. Jim Saveland introduced several tools that participants could incorporate into their operations. He challenged ma nagers to:

 Discover a collective meaning of applying HRO in BLM fire management operations that is larger than any one individual.

 Be bette r able to “speak truth to power” (respectful interaction)

.  Be able to incorporate new concepts into their daily langu age.



## H O W T O 

## L E A D 

## I T 

## ~ L O O K F O R 

## S M A L L 

## W I N S

Successful implementation of the HRO principles can be found in adopting a small wins strategy which is “a change strategy built around consistent, incremental small changes that produce

visible results.” (Karl E. Weick)

As the BLM moves forward with HRO implementation, the intent is to provide support from the

national level to the individual BLM state implementation plans

, which are designed to fit their cultures and specific ways of doing business.

During the t raining session , each state was asked to identif y what they believed were

achievable small wins and what self audits would be conducted to test their organization’s HRO principles. The following two pages list each BLM state’s commitments to maintaining th ese principles.

Jim Douglas presenting 2009 National Wildland Fire Safety Award to Cli ff Hutton, Colorado State Office “ M ost organizations try to take on large changes and never get to them . If you look for small wins...if they fail...no big deal. You dust yourself off and try something else

, but you don’t get bogged down on a large undertaking. ”

~ Karl E. Weick10 

## H O W T O 

## L E A D 

## I T 

## ~ S T A T E 

## C O M M I T M E N T S

A LASKA

 Introduce HROs as a sense of duty and obligation.

 Valu e diverse opinions.

 Nurture value of the devil ’ s advocate role.

 R enew commitment to firefighters in the field.

 Require that m anagers v isit the field to gain an

understand ing of field op eration s.

 Nurture the values of trust and honesty.

 Conduct all

- employee AFS meeting s.

 Support cohesion in the o rganization

.  Embra ce SAFENET s and require a faster and

cleaner submission to managers

.  Incorporate HRO language in to work operations.

A RIZONA

 Formalize support of the HRO principles.

 Involve line o fficers.

 Conduct premortem exercises (fire operations, fuels, and dispatch) on a project

- by

- project

basis

.  L earn from our success es

— c ritical t hinking of operations.

 Incorporate the HRO principles in to mission

statements.

 Involve FOS s by having them train their crews

.  Utilize HRO subject matter experts during presentations

.  Decrease the focus o f a district mentality and

instill a more corporat e mentality

.  Leave egos at the door.

 Encourage ownership at the ground level.

 Listen

.  Instill a bounce

- back mentality.

 Post premortem s on the state S harepoint site

.

C ALIFORNIA

 Instill getting

- back

- t o

- basics and pay

- attention

t o

- details attitude s

.  Consider worst outcomes during briefings

 Foster a n o

- recourse

- for

- reporting culture

.  Create an anonymous reporting blog or system

.  H ave outsiders look inside and give feedback.

 Get another perspective . Have i nternal agency

SME s review various programs

.  Ensure proper authority to empower people to

make decisions

.  Sup port our people when they make decisions.  Promote the concept of s hared risk.

 W ork as a team recognizing everyone ’s strengths.

 Seek the talents in each module.

 Train through lessons learned.

 Use a reward system.

 Instill trust in the organization.

 Have top m anagement get in touch with ground forces.

 Ensure that the rollout has a clear and consistent message.

C OLORADO

 Provide a formal and informal level

u nderstanding of HRO from state to ground

level s

.  Utilize the Oregon poste r card (see back cover) in training to keep HRO foremost in firefighters’ minds.

 Use the premortem process prior to first spring

burn /c utting op eration / aviation mission.  Instill HRO principles in weekly conference

calls by asking what they see as our weak signals.

 Utilize current reporting systems more effectively

.  Tie HRO principles into field drills and improvisations.

N EW M EXICO

 F oster our current commitment of the HRO principles fr o m top management level s to the ground firefighter

.  Introduce HRO p rinciples in the preseason meetings and r efreshers.  Do premortem s to identify weak signals.

 Create a signal for HRO.

 Track our progress.11 I DAHO

 Keep lines of c ommunication open and make sure everyone is on board

.  N urture HRO principles at all levels.

 I nstill premortem s as part of regular jobs.

 R evisit past lessons and reports.

 G o through AARs an d see if we acted on the findings and got t o the root cause.  Keep the “ b ubble ” in line (c an be an incident, district, crew and it is not static but

continuous )

.  Identify , develop and use internal experts.

 Have r edundancy in cross training.

 Learn from the outside of the organization.

N EVADA

 Introduce HRO at the state preseason meeting.

 Perform weekly FMO calls to check on the status of HRO implementation.  Perform premortem s; e.g., fuels program.

 Do an AAR in the f all to determine how we did

and roll out at an interagency meeting.

O REGON

 Perform p remortem s and use as a way to build the spring meeting

.  Address worst

- feared failure s

.  Distribute and promote the HRO card (see back cover) to the State leadership fuels team

members in the spring.

 Focus HRO training on GS 3

- 9 personnel and western Oregon militia.  Show top

- level commitment and foster lower

level ownership

.  Develop an HRO toolbox

.  U tilize the Lessons Learned Center’s website

.  Develop a learning culture to foster a just and reporting culture

.

M ONTANA

 Perform premortem s for burn plans.

 Use meeting s and weekly calls to introduce

the HRO ideas.

 Look at what we have taken for granted ; e.g., drip torch e s.

 Increase refreshers and currency training.

 I mprove the feedback loop.

 Eliminate surprises when events occur

.  Talk about event s regularly.

 D evelop a state

- wide matrix to identify skills

and use them when needed.

 Keep all AFMO s and FMO s on IMTs current with assignments.

 Expose FMO s to different districts.

 Develo p ways to present HRO to all levels.

U TAH

 Foster a commitment to the HRO principles.

 Present HRO to D istrict Managers during preseason meeting s and get buy in.  Do an HRO workshop within the next year

.  Incorporate HRO into SFM plans.

 S tart a reporting reward system.

W YOMING

 Perform weekly premortem s fr o m the ground level up.

 Perform m onthly external premortem s with

outside entities.

 Review the LCES checklist and personalize

and de

- simplify them.

 Commit to leadership training.  Provide spot checks on the line. Have crews rotate spot check s on other crew s’ engine s

.
 Appoint a S ituation O fficer.

 R ecogni ze successes.

 U tilize external experts (fallers and city fire
department personnel)

.

NIFC

 Secure an agenda spot on s tate a viation

m anager calls to determine the status of HRO implementation.

 Strengthen our reporting system.

 Incorporate the Australian method of filling out

a card fro m the field v er s us web

- based
systems.  Embrace and rely on new tech nology and start utilizing tools such as social networking.

 Adopt the premortem process.

 I ncorporate HRO pri nciples into national

reviews.

 Brief national safety team and risk management committees on HRO p rincipl es and attempt to i ntegrate into NWCG.12 

## C L O S I N G 

## C O M M E N T S 

## ~ D A V E 

## T H O M A S

Thomas explained that learning these principles is only the first step. Leading an HRO is a continuous discipline that requir es practice, diligence , and ownership at all levels of an organization. He noted that it is easy to lose the HRO principles in the midst of other fire related terminology . For example, Deference to Expertise may seem at odds with command and

control

, Reluctance to Simplify may appear at odds with our checklist mentality and custom

, and Sensitivity to Operations may seem to oppose standard operating procedures

. But they are not opposites! They actually work together and are continuous. The key is to maintain a learning

culture an d dive deep into these five HRO principles at all levels of the organization

.



## C L O S I N G 

## R E M A R K S 

## ~ T I M 

## M U R P H Y

“The word passion was used a lot this week, and you people really have it. I asked at the beginning of this week if we are prepared for the unexpected. I hope that because of this week you are better prepared to do your jobs...I know I am. We may be practic ing this already but looking at the five HRO principles will help us become even better prepared...I encourage you all to lead your groups into a safe and successful fire season.” “I have not seen any organization like this come together with their top management to embrace these concepts...what has happened here this week has been remarkable.” ~ Dave Thomas “The difference between a beginner and the master

— the master practices a whole lot more.”

~ Yehudi Menuhin

## F U R T H E R 

## I N F O R M A T I O N O N 

## H R O S

The Wildland Fire Lessons Learned Center website has an abundance of material on HROs in fire operations at http://www.wildfirelessons.net/HRO.aspx

.



## R E C O M M E N D E D 

## R E A D I N G O N 

## H R O S

 Beyond Aviation Human Factors, Daniel E. Maurino, et al.

 M anaging the Risks of Organizational Accidents, James Reason

 Managing the Unexpected, Karl E. Weick and Kathleen M. Sutcliffe

 New Challenges to Understanding Organizations, Karlene H. Roberts

 Normal Accidents , Charles Perrow

 The Limits of Safety, Scott D. Sagan



## A C K N O W L E D G M E N T S

The High Reliability Organizing: What It Is, Why It Works, How to Lead It training session and this publication could not have occurred without the contributions of the following:

John Glenn Division Chief, Fire Operati ons

Casey O’Connell Staff Assistant, Fire Operations

Sean Cross

Chief

, Preparedness/Suppression

Standards , Fire Operations Michelle Ryerson Safety Manager, Fire & Aviation

BLM National Training Center
Phoenix, AZ

BLM Fire Training Unit

Dave Thomas, HRO consultant and USFS retiree, Donna Hunter, mental health therapist and organizational learning and adaptive leadership consultant, and Jim Saveland, Program Manager for Social, Economic & Decision Sciences, Rocky Mountain Research Center, facilitated the training.

In addition, the literary works and research of the following subject matter experts were instrumental to the success of the training:

Dr. Karlene Roberts, Professor Emeritus Haas Management of Organizations Group University of Ca lifornia

Dr. Karl E. Weick, the Rensis Likert Distinguished University Professor of Organizational behavior and Psychology

Dr. Kathleen Sutcliffe, University of Michigan Business School

Gene Rochlin, Emeritus Professor in the Energy and Resources Group at the University of California, Berkeley

James Reason, author of Managing the Risks of Organizational Accidents( HRO poster card ~ Courtesy of Oregon BLM )