1. Company LOGO High Reliability Organizing Implementation in Fire Crews

2. Agenda 1. Use Fire Analysis to go to HRO 2. Five HRO Processes 3. Requisite Culture for Success

3. Fire Management

4. Wildland Fire an HRO? “High Reliability Organizations –Nuclear power plants –Aircraft carriers – Wildland firefighting crews

5. Maybe yours, but not mine! How about our prescribed fire programs? Common “surprises” from 28 Escapes and 2 Near Misses 1996-2004 LLC Report

6. Mindfulness To be mindful Mindful updating

7. 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

8. 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

9. Triangle of Probability 1 30 300

10. Triangle of Probability 20 600 6000

11. 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

12. 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.

13. 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.

14. 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

15. 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:

16. Four Subcultures –Reporting culture –Just culture –Flexible culture –Learning culture

17. Dependency Diagram First Second ThirdFourth Just Culture Trust Clarity Reporting Culture Reporting Relationships Flexible Culture Adaptable Learning Culture

18. Toward a Mindful Culture First Second ThirdFourth Just Culture Trust Clarity Reporting Culture Reporting Relationships Flexible Culture Adaptable Learning Culture

19. Pay Attention Differently You STOP concentrating on some things. You START concentrating on other things. To Be Mindful Is to “See more Clearly” Not to Think Harder and Longer

20. “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)

21. Plans and Their Drawbacks Plans influence what people see Plans can limit our view of our capabilities Plans focus attention on what we expect

22. Preoccupation with Failures All Failures Especially The Small Ones

23. Learning by Failure – Hard Learning moments are short-lived Don’t wait Do it the right way

24. James Reason, 2006

25. The Person Model

26. The Legal Model

27. The System Model

28. Satisfying with “Justice Fruit”

29. Upward and Outward

30. A Balanced Approach?

31. Use A Balanced Approach? Person Approach? Legal Approach? System Approach? Learning Approach

32. Learning requires some preconditions: psychological safety learning orientation efficacy Learning Ground Rules

33. 2. Reluctance to Simplify Our Expectations

34. 3. Operations-Sensitive Leadership Encourage others to speak up Check for comprehension “Over Learn” new routines

35. 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

36. 5. Defer to Expertise HROs shift decisions toward expertise and experience.

37. 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

38. STICC – Explain Yourself Situation Task Intent Concern Calibrate

39. 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?

40. Five Continuous Processes deference preoccupation reluctance sensitivity commitment Manage the Unexpected Mindful Updating

41. Five Processes 1. Preoccupation with failure 2. Reluctance to simplify 3. Sensitivity to operations 4. Commitment to resilience 5. Deference to expertise

42. Cultural Progression to HRO Just Reporting Flexible Learning

43. 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.”

44. Where we are going

45. Information to Knowledge Informed Culture Timely Available Candid Disseminated Learning Culture

46. Agenda 1. Use Fire Analysis to go to HRO 2. Five HRO Processes 3. Requisite Culture for Success

47. Commitment – Pick Two 1. Preoccupation with failure 2. Reluctance to simplify 3. Sensitivity to operations 4. Commitment to resilience 5. Deference to expertise

48. HRO Support at LLC www.wildfirelessons.net

50. HRO Support at MFC www.myfirecommunity.net

51. Questions? Contact Us Paula Nasiatka, LLC Manager –(520) 799-8760, pnasiatka@fs.fed.uspnasiatka@fs.fed.us David Christenson, LLC Asst. Mgr. –(520) 799-8761, dchristenson@fs.fed.usdchristenson@fs.fed.us Brenna MacDowell, LLC Editorial Asst. –(520) 799-8763, bmacdowell@fs.fed.usbmacdowell@fs.fed.us