Company

LOGO High Reliability Organizing

Implementation in Fire Crews

Agenda

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

2. Five HRO Processes 2. Five HRO Processes

3. Requisite Culture for Success 3. Requisite Culture for Success

Fire Management

Wildland Fire an HRO?

• “High Reliability Organizations– Nuclear power plants– Aircraft carriers– Wildland firefighting crews

Maybe yours, but not mine!

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

Mindfulness

•To be mindful

•Mindful updating

The past settles its accounts

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

Preventing Chaos in a Crisis, Lagadec, p. 54

1. Preoccupation with Failure

Thinking about our own fire dispatch unit, can we honestly say:

• We regard near misses as a kind of failure that reveals potential danger rather than as evidence of our success and ability to avoid danger

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

Triangle of Probability

1

30

300

Triangle of Probability

20

600

6000

2. Reluctance to Simplify

Thinking about our fire crew, can we say:

• People around here take nothing for granted

• People are encouraged to express different points of view

3. Sensitivity to Operations

• During an average day, people come into enough contact with each other to build a clear picture of the situation.

• People are familiar with operations beyond one’s own job.

4. Commitment to Resilience

• There is a concern with building people’s competence and response repertoires.

• People have a number of informal contacts that they sometimes use to solve problems.

5. Deference to Expertise

• If something out of the ordinary happens, people know who has the expertise to respond

• People in this organization value expertise and experience over hierarchical rank

Toward a “Mindful Culture”

• A healthy safety culture consciously creates mindfulness.

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

• Informed cultures result from four co-existing subcultures:

Four Subcultures

–Reporting culture

–Just culture

–Flexible culture

–Learning culture

Dependency Diagram

First Second Third Fourth

JustCulture

TrustClarity

ReportingCulture

ReportingRelationships

FlexibleCulture

Adaptable

LearningCulture

Toward a Mindful Culture

First Second Third Fourth

JustCulture

TrustClarity

ReportingCulture

ReportingRelationships

FlexibleCulture

Adaptable

LearningCulture

Pay Attention Differently

• You STOP concentrating on some things.

• You START concentrating on other things.

• To Be MindfulIs to “See more Clearly” Not to Think Harder and Longer

“See more clearly”

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

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

• Focus on what is happening here and now (operations)

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

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

Plans and Their Drawbacks

• Plans influence what people see

• Plans can limit our view of our capabilities

• Plans focus attention on what we expect

Preoccupation with Failures

All Failures

Especially The Small Ones

Learning by Failure – Hard

Learning moments are short-lived

Don’t wait

Do it the right way

James Reason, 2006

The Person Model

The Legal Model

The System Model

Satisfying with “Justice Fruit”

Upward and Outward

A Balanced Approach?

Use A Balanced Approach?

• Person Approach?

• Legal Approach?

• System Approach?

• Learning Approach

• Learning requires some preconditions:

psychological safety

learning orientation

efficacy

Learning Ground Rules

2. Reluctance to Simplify

Our Expectations

3. Operations-Sensitive Leadership

• Encourage others to speak up

• Check for comprehension

• “Over Learn” new routines

4. Commitment to Resilience

• A combination:–Keeping errors small and

–Improvising workarounds that keep the system functioning

• Build dynamic thinking skills

• Develop creativity

• Value variability

5. Defer to Expertise

• HROs shift decisions toward expertise and experience.

Sensemaking vs Decisionmaking

• “If I make a decision it is a possession; I take pride in it; I tend to defend it and not to listen to those who question it.

• If I make sense, then this is more dynamic and I listen and I can change it.

• A decision is something you polish. Sensemaking is a direction for the next period.”

--Paul Gleason

STICC – Explain Yourself

• Situation

• Task

• Intent

• Concern

• Calibrate

Continually Ask Yourself

• Scanning questions:– Can I see weak signals of failure and make

sense of them?– How many different slides do I have that

apply to this situation?– Am I aware of the unfolding situation? – Do I have the skills to make do? – Who knows how to do what?

Five Continuous Processes

deference

preoccupationreluctance

sensitivity

commitment

Manage the Unexpected

Mindful Updating

Five Processes

1. Preoccupation with failure 1. Preoccupation with failure

2. Reluctance to simplify 2. Reluctance to simplify

3. Sensitivity to operations 3. Sensitivity to operations

4. Commitment to resilience 4. Commitment to resilience

5. Deference to expertise 5. Deference to expertise

Cultural Progression to HRO

JustJust ReportingReporting FlexibleFlexible LearningLearning

Mindfulness Defined

• “By mindfulness we mean the combination of–Ongoing scrutiny of existing expectations,

–Continuous refinement and differentiation of expectations based on newer experiences,–Willingness and capability to invent new expectations that make sense of unprecedented events,–A more nuanced appreciation of context and ways to deal with it,–And identification of new dimensions of context that improve foresight and current functioning.”

Where we are going

Information to Knowledge

Informed Culture

Timely AvailableCandid Disseminated

Learning Culture

Agenda

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

2. Five HRO Processes 2. Five HRO Processes

3. Requisite Culture for Success 3. Requisite Culture for Success

Commitment – Pick Two

1. Preoccupation with failure 1. Preoccupation with failure

2. Reluctance to simplify 2. Reluctance to simplify

3. Sensitivity to operations 3. Sensitivity to operations

4. Commitment to resilience 4. Commitment to resilience

5. Deference to expertise 5. Deference to expertise

HRO Support at LLCwww.wildfirelessons.net

HRO Support at MFCwww.myfirecommunity.net

Questions? Contact Us

• Paula Nasiatka, LLC Manager– (520) 799-8760, pnasiatka@fs.fed.us

• David Christenson, LLC Asst. Mgr.– (520) 799-8761, dchristenson@fs.fed.us

• Brenna MacDowell, LLC Editorial Asst.– (520) 799-8763, bmacdowell@fs.fed.us