Fire today ManagementVolume 68 • No. 2 • Spring 2008
MManaginganaging the the UUnexpectednexpected
United States Department of Agriculture Forest Service Coming Next… In the next issue of Fire Management Today (68[3] Summer 2008), visit countries around the world and learn from international experts about the challenges of firefighting globally. Visit our familiar friends in Australia and Canada, then jet across the world to the Mediterranean and introduce yourself to five countries that call themselves the “Fire club.” [Excerpt] “Fire is a global phenomenon. Worldwide, fire can play a role in either maintaining or threatening natural habitats and human soci eties. In any case, we must consider the global context for our actions, as well as the best role each nation can play in managing fire for both people and nature.”
Fire Management Today is published by the Forest Service of the U.S. Department of Agriculture, Washington, DC. The Secretary of Agriculture has determined that the publication of this periodical is necessary in the transaction of the public business required by law of this Department.
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Ed Schafer, Secretary Melissa Frey U.S. Department of Agriculture General Manager
Abigail R. Kimbell, Chief Cindy White Forest Service Managing Editor
Tom Harbour, Director Madelyn Dillon Fire and Aviation Management Editor
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Fire Management Today 2 Fire Volume 68 • No. 2 • Spring 2008 Management today co n t e n t s On the Cover: Anchor Point—Adapting to Change ...... 4 Tom Harbour
Building the Foundation for a Learning Culture ...... 5 . Paula Nasiatka Making Sense of Organizing for High Reliability and Learning . . 8 . Jim Saveland The Genesis and Evolution of High Reliability Organizing . . . .12 . Michael DeGrosky Organizing for Higher Reliability: Lessons Learned . . . . 14 . From Wildland Firefighters On the Cover: Firefighters take a look Karl E. Weick and Kathleen M. Sutcliffe back to see that their handline is holding on the West Hunter Prescribed Fire in the Okanogan-Wenatchee National The Cerro Grande Prescribed Fire Escape Meets ...... 20 . Forest in Washington State. Photo: Eli the First “Managing the Unexpected” Workshop Lehmann, Forest Service, Mount Baker– Paul Keller Snoqualmie National Forest, Concrete, WA, 2004. Opening the Darkest Chapter of My Professional Career . . . 26 . Matt Snider The spring issue of Fire Management Today will feature an indepth examination of how a High Reliability Organization Case Study: Is High Reliability Organizing ...... 28 (HRO) provides a foundation for how we the Next Best Thing? You Decide all should be operating in wildland fire Brett Fay management. Case Study: The High Reliability Organizing Field Study . . . 30 . The issue also highlights how the Wild- land Fire Lessons Learned Center is of the Okefenokee National Wildlife Refuge encouraging firefighter safety by pro Paul Keller moting organizational learning and the center’s ongoing efforts to make the entire Case Study: High Reliability Organizing and Prescribed Fire . .32 . wildland fire community a healthier learning culture. on the Boise National Forest David Olson and Deirdre Dether The Forest Service’s Fire and Aviation Management Staff has adopted a logo Spreading the Word on High Reliability Organizing . . . . .35 . reflecting three central principles of wildland Paul Keller fire management: Understanding Mindfulness ...... 38 • Innovation: We will respect and value thinking minds, voices, and thoughts of Dave Thomas those that challenge the status quo while focusing on the greater good. A Personal Account of Resilience and Prescribed Fire . . . . 42 . Riva Duncan • Execution: We will do what we say we will do. Achieving program objectives, Assessing High Reliability Practices ...... 45 improving diversity, and accomplishing targets are essential to our credibility. in the Wildland Fire Community Anne Black • Discipline: What we do, we will do well. Fiscal, managerial, and operational Proceedings of the Wildland Fire Safety Summits ...... 49 . discipline are at the core of our ability to fulfill our mission. Martin E. Alexander and Bret W. Butler
sh o r t Fe a t U r e s Coming Next ...... InsideFrontCover Web Sites on Fire ...... 11 Firefighter and public safety is our first priority. Guidelines for Contributors ...... 51
Volume 68 • No. 2• Spring 2008 3 Anchor by Tom Harbor Director, Fire and Aviation Management Point USDA Forest Service ad a p t i n g t o ch a n g e
ire and aviation manage ment is increasingly complex. Actually implementing a wide variety of responses F Interagency and social expec and becoming a flexible, innovative, learning tations for interoperability, along organization are key linchpins to our future. with enhanced risk management and improved efficiency, provide a basis for an energetic program. Our Fire management professionals, It’s harder than some people might fire and aviation program in the line officers, and communicators all think. We lined out the manage Forest Service is working hard to worked together to temper expecta ment action points where we could “stay ahead of the game.” tions about what we can do with a fight the fire safely and actually wildland fire that is exceeding all have some effect on its progress. Our more vibrant implementa our measurements and is very dan tion of appropriate management gerous. Through written analyses The Forest Service workforce response (AMR) is an example and shared information, we were steeped in a tradition of hard work of strategic and cultural change. more creative in approaching wild- and service and we are proud of it. While “appropriate” is a value- land fires that we knew would resist By being smarter and more patient, laden term, as used in the Federal our best traditional control efforts. we are maintaining that service Wildland Fire Management Policy, We learned from each other and, ethic every day, whether we are dig the term is meant to encompass a where we could, implemented dif ging line or digging in and prepar wide variety of response to wildland ferent suppression strategies than ing to fight the fire on our terms. fire. in years past. We are more effective when we put The future is described not only the right resources in the right by AMR but by High Reliability place at the right time. Organizations (HRO). HROs con We are more effective stantly adapt to change. Change is when we put the right Actually implementing a wide vari happening with us; in some places, resources in the right ety of responses and becoming a 2007 brought about dramatic place at the right time. flexible, innovative, learning orga change. nization are key linchpins to our future.
Fire Management Today 4 BUilding t h e Fo U n d a t i o n F o r a le a r n i n g cU l t U r e
Paula Nasiatka
he acknowledged need for an interagency Wildland Fire A necessary link and Six Tasks T Lessons Learned Center to obvious relationship Critical to serve the country was rooted in the Tridata Firefighter Safety Awareness exists between these Organizational Study, conducted after 14 firefight two processes: High Learning ers perished in Colorado’s 1994 Reliability Organizing and South Canyon Fire. Organizational Learning. According to David A. Garvin of Harvard Business School, six Although originally proposed as a specific tasks are critical to orga center to focus on firefighter safety, a continuing and productive rela nizational learning. By engag early firefighter community surveys tionship between the wildland fire ing in these tasks, a unit can indicated that a desire existed for community and Harvard Business significantly improve both its such a wildland fire lessons learned School. programs and its learning. These center to take a more holistic six critical tasks can be directly approach by looking at organiza The Lessons Learned Center devel applied to all wildland fire man tional learning in wildland fire and oped a road map for its work that agement programs: its organizational culture. centered on organizational learn ing and the six critical tasks of a 1. Continually collect intelli As the Wildland Fire Lessons learning organization (see sidebar). gence about the environment, Learned Center organized in 2002, Center staff believed that if they, 2. Learn from the best practices it began to benchmark other les as a knowledge resource center, of other organizations, sons learned centers to ascertain were going to help the wildland fire 3. Learn from your own experi their foundational lessons and to community become better at orga ences and past history, discover what practices work and nizational learning, they too had to 4. Experiment with new which ones to avoid. walk the walk and talk the talk. approaches, 5. Encourage systematic prob Less than a year after inception, lem solving among all mem Lessons Learned Center staff con High Reliability Organizing and bers of your unit, and tacted Harvard Business School 6. Transfer knowledge through Professor David A. Garvin, author Organizational Learning out the organization. of Learning in Action, to ask for Several members of the wildland help. fire community had been work For more information on these ing with University of Michigan six critical tasks, see the article Garvin offered to come out to our Business School Professor Karl “Measuring Success in Your center based in Tucson, AZ, to Weick after meeting him at the first Fuels Program” in the 2006 discuss organizational learning— Human Factors in Wildland Fire issue of Fire Management Today particularly organizational culture Conference in 1995. (Vol. 66, No. 4). and “leading learning”—with inter- agency fire professionals. The first Weick’s work in sensemaking of Complexity, authors Weick and meeting initiated the foundation for and developing a High Reliability Kathleen Sutcliffe reference how Organization (HRO) resonated HROs are learning organizations. Paula Nasiatka, coordinator of this issue with many wildland fire profession Thus, a necessary link and obvious of Fire Management Today, is the Center als. In Managing the Unexpected: relationship exists between HROs Manager of the Wildland Fire Lessons Learned Center, Tucson, AZ. Assuring High Reliability in an Age and Organizational Learning.
Volume 68 • No. 2• Spring 2008 5 This first meeting initiated the foundation for a Instruction on learning styles continuing and productive relationship between and various teaching methods— In May 2007, a successful pilot the wildland fire community and Harvard workshop called Facilitating an Business School. HRO in Wildland Fire was held in Nebraska City, NE.
High Reliability Organizing is a fire management operations are • Participants of the Train-the- way to think logically about how to most pertinent at this time? Trainer Workshop will conduct proactively develop special skills to three High Reliability Organizing avoid—or be better prepared for— The group developed a mission in Wildland Fire Workshops unexpected events. It is a way to statement describing how High annually at various locations make sense of the unexpected when Reliability Organizing fits into the throughout the country. it does happen, and quickly recover Wildland Fire Lessons Learned vital systems. An HRO is the foun Center’s comprehensive organiza Goal Two—Education dation for how wildland fire man tional learning strategy. and Outreach agement operates and should strive An HRO education and outreach to operate. Goals Developed component will help ensure that Distinct goals were then developed stakeholders—both inside and More than 300 fire professionals for meeting the HRO mission. To outside fire management—have attended three national Managing receive further input and validate a thorough knowledge of High the Unexpected in Wildland Fire the goals, they were discussed with Reliability Organizing and how it Workshops—that featured Weick a larger representation of wildland aligns with other efforts. A con and Sutcliffe. Followup critiques, fire professionals who had also sistent message—integrated with evaluations, and after-action been involved with HROs and the other national fire management reviews from students and faculty national Managing the Unexpected initiatives—about the value of an indicated that the workshops were Workshops. HRO will be delivered to stakeholders. successful and that High Reliability Organizing is an important com Goal One—Curriculum Goal Three—Measuring ponent of the fire management toolbox. Curriculum for workshops and Effectiveness of High seminars was developed to include: Reliability Organizing Where Do We Go Next A critical need exists to answer fun • An Advanced HRO Seminar— damental questions about the time, With High Reliability participants worked with Weick Organizing money, and effort that are invested and Sutcliffe in a 2-day graduate- into HROs: Is it working and is it Following the third workshop, style session (25 participants meeting the mission statement a small interagency group gath attended this seminar in February developed at the Wildland Fire ered at the Wildland Fire Lessons 2007). This seminar set the stage Lessons Learned Center? Learned Center in August 2006 to for an interagency cadre to dis answer the following key questions: cuss in detail the five HRO prin ciples and learn how best to teach • Should we continue to use and apply each principle to work High Reliability the national Managing the practices. Organizing is the Unexpected Workshops as the • Train-the-Trainer Workshops— foundation for how all primary method of teaching High a cadre of master instructors Reliability Organizing? (Advanced HRO Seminar par members of the wildland • Is it time to change or modify ticipants) will teach effectively fire community should approaches to teaching how to conveying HRO principles to operate in wildland fire develop an HRO? select groups of approximately 50 management. • What new approaches to applying students per workshop. High Reliability Organizing to
Fire Management Today 6 We realize that all of these wildland fire focus “Organizational learning is there fore likely to be heavily influenced areas should be presented and discussed by the behavior of leaders. If lead in an integrated, cohesive fashion. ers prompt dialogue and debate through active questioning and listening, learning is likely to be center develop its mission, vision, encouraged. Mission goals, and objectives for the next Statement 5 years. HRO principles have been If they signal the importance of consistently discussed as key foun spending time on problem identi “The Wildland Fire Lessons dational elements. fication, knowledge transfer, and Learned Center actively pro As reflected in our mission state reflective post-audits, these activi motes a learning culture to ment, HRO leadership, doctrine, ties are likely to flourish. enhance and sustain safe and and principles-based decisionmak effective work practices in the ing are all represented. Teaching If they behave in ways that wildland fire community. or referring to these focus areas as acknowledge their own openness isolated undertakings does little and willingness to entertain alter The center provides opportu to build or strengthen our learn native points of view, options are nities and resources to foster ing culture. Instead, all of these likely to multiply and diverse alter collaboration among all fire wildland fire focus areas must be natives are likely to be voiced. professionals, facilitates their presented and discussed in an inte networks, provides access to grated, cohesive fashion. Leadership behavior is thus the state-of-the-art learning tools, vehicle that gives life to supportive and links learning to training.” Moving Forward learning environments and ensures According to Harvard Business the effective implementation of School organizational learning critical learning processes.” experts, three building blocks form A set of significant questions a learning organization: References Edmonson, A; Garvin, D.; Gino, F. 2007. Is have been designed to answer yours a learning organization? In press. this crucial question. These ques 1. A supportive learning environ Boston, MA: Harvard Business Review. tions are being pursued in the ment, research project “Assessing High 2. Concrete learning processes and Garvin, D. 2000. Learning in action. practices, and Boston, MA: Harvard Business School Reliability Organizing in Wildland Press. Fire” being conducted by Kathleen 3. The practice of reinforcing lead Sutcliffe and Michelle Barton of the ership behaviors. TriData Corporation, 1996. Identifying the organizational culture. Leadership, University of Michigan Business human factors, and other issues School, in cooperation with the Two questions that wildland fire impacting firefighter safety. Bureau Aldo Leopold Wilderness Research organizations should constantly of Land Management Contract: #1422-N-651-C5-3070. Institute and the Boise National ask: Have we, as a fire community, firmly established these building Forest. Weick, K.; Sutcliffe, K. 2001. Managing the blocks? Have we done better with unexpected: Assuring high performance Strategic Plan some aspects of organizational in an age of complexity. University of learning than others? Michigan Business School Management The Wildland Fire Lessons Learned Series. San Francisco, CA: Jossey-Bass Center recently completed its first Publishers (2nd ed. now available). I’ll leave you with an appropriate strategic planning effort. An inter- quote from Is Yours a Learning agency planning team, along with Organization? by Amy Edmonson, wildland fire stakeholders from David Garvin, and Francesca Gino around the country, helped the (2007):
Volume 68 • No. 2• Spring 2008 7 Ma k i n g se n s e o F or g a n i z i n g F o r hi g h reliaBility a n d le a r n i n g Jim Saveland
he complex world of wildland fire management is fraught Mindfulness is a rich awareness of discriminatory T with great challenges: detail and an enhanced ability to discover and correct errors that could escalate into a crisis. • Dramatically improve firefighter and public safety; • Reduce the costs of large wild and orders form an important piece shifting from bad apples to complex fires; of the history of job safety and still systems. Such a journey takes us • Restore fire-adapted ecosystems represent a very relevant story in a on a path toward leadership in risk across large landscapes, while factory or office building. Yet, they management. minimizing the nuisance of occupy less and less of our atten smoke and the chance of escaped tion on the fireline—and rightly so. Organizing for High fires; and Reliability • Achieve all of these challenges The 1970 Act assumes that we have There are five principles of high in a polarized political environ more control of our environment reliability (Weick and Sutcliffe ment while the wildland urban than we actually do. It assumes that 2001): interface grows rapidly and the the head of the agency provides an climate changes. environment free from safety and 1. Preoccupation with failure, health hazards and that all employ 2. Reluctance to simplify, All of these challenges require wild- ees have to do is comply with stan 3. Sensitivity to operations, land fire managers to be experts in dards, policies, and directives and 4. Commitment to resilience, and risk management. Unfortunately, use protective equipment. These 5. Deference to expertise. outdated safety policies and think assumptions are part of what pro ing are not much help for moving fessor of human factors and flight These principles are explained in in this direction. The Occupational safety Sidney Dekker (2006) calls detail elsewhere in this issue of Fire Safety and Health Act of 1970, “the old view of human error”— Management Today. Perhaps the Executive Order 12196 of 1980, also known as the “The Bad Apple one principle that gives people the and 29 Code of Federal Regulations Theory.” Simply stated, complex most difficulty is “preoccupation 1960 require the heads of Federal systems would be fine, were it not with failure.” People like to cel agencies to furnish to employees for the erratic behavior of some ebrate success and find it difficult places and conditions of employ unreliable people (bad apples) in it. to focus on failure. Yet, this is pre ment that are free from job safety The Bad Apple Theory is in many cisely what is required. and health hazards. respects a recasting of Douglas McGregor’s (1985) famous “Theory Think of it like defensive driving: While this paternalistic attitude X” back in 1960. being constantly alert to the pos and mental model of providing a sibility of what could go wrong safe work environment is an impor The wildland fire management and having a mental plan of action tant part of the safety story, it is community is not waiting for the to deal with the situation should only a small part of today’s story heads of agencies to furnish places it arise. Practicing the five prin of complex systems operating in free from job safety and health ciples of high reliability is called chaotic environments. These acts hazards. Rather, this community is “mindfulness” (Weick and Sutcliffe beginning to explore state-of-the 2001, Weick and Putnam 2006). Jim Saveland is the program manager art safe and effective operations: Mindfulness is a rich awareness for human factors and risk management organizing for high reliability and of discriminatory detail and an at the Forest Service’s Rocky Mountain learning. The focus of attention is enhanced ability to discover and Research Station, Fort Collins, CO.
Fire Management Today 8 correct errors that could escalate I’ve previously discussed (Saveland desire for zero fatalities and serious into a crisis. 2005) the need to talk about the accidents with the recognition of two types of errors: misses and inherent risks of fire management In contrast, a tendency toward false alarms. While we in the wild- operations. “mindlessness” is characterized by land fire community tend to focus “a style of mental functioning in on the miss and near-miss, false These competing perspectives can which people follow recipes, impose alarms lead to what Scott Snook be thought of as an example of the old categories to classify what they (2000) calls “practical drift.” Stockdale Paradox (Collins 2001). see, act with some rigidity, operate on automatic pilot, and mislabel unfamiliar new contexts as familiar One of the common themes of “human factors” old ones.” A mindless mental style is moving away from focusing on individual works to conceal problems that are behavior and focusing more attention on getting worse (Weick and Sutcliffe systems and processes. 2001).
Weick and Sutcliffe (2001) incor Peter Senge (1994) talked about the The name refers to Admiral Jim porate James Reason’s (1997) work five disciplines of a learning orga Stockdale, the highest ranking on a safety culture as an informed nization: U.S. military officer in the "Hanoi culture, a vital component of Hilton" prisoner-of-war camp dur organizing for high reliability. 1. Mental models (deeply ingrained ing the height of the Vietnam War. Reason argues that it takes four assumptions, generalizations, or The Stockdale Paradox goes like subcultures to ensure an informed even pictures and images that this: “retain faith that you will pre culture. Assumptions, values, and influence how we understand the vail in the end, regardless of the artifacts must line up consistently world and how we take action); difficulties; and at the same time, around the issues of: 2. Personal mastery (becoming confront the most brutal facts of experts at our craft); your current reality, whatever they • What gets reported when people 3. Building shared vision (the might be.” In other words, if this make errors or experience near capacity to develop and hold a perspective is applied to the wild- misses (Reporting Culture); shared picture of the future we land fire arena: we must retain faith • How people apportion blame seek to create); in a vision of zero fatalities and when something goes wrong 4. Team learning (starts with dia serious accidents and at the same (Just Culture); logue, the capacity of members time confront the brutal facts of the • How readily people can adapt to of a team to suspend assump inherent risks of our current wild- sudden and radical increments tions and enter into a genuine land fire reality. This vision of zero in pressure, pacing, and intensity thinking and acting together); fatalities is not mere wishful think (Flexible Culture); and and ing. The first step to achieving it is • How adequately people can con 5. Systems thinking (using causal- believing it, seeing it in your mind’s vert the lessons that they have loop diagrams as a robust lan eye. That’s what vision is about. learned into reconfigurations of guage for telling stories about assumptions, frameworks, and complex systems). In an effort to make the concepts of action (Learning Culture). organizational learning more prac Today, we seem to be struggling tical, David Garvin (2000) came up Organizing for Learning with Senge’s third discipline—our with six critical tasks—that, by the notion of building shared vision. In way, guide the day-to-day opera The need to develop a flexible and our haste and impatience, we typi tions of the interagency Wildland a learning culture brings us to cally charge a small group to go Fire Lessons Learned Center: research on organizational learn off and develop a vision, and then ing. Organizing for high reliability push it through the organization. 1. Collect intelligence about the and organizing for learning have a However, this is an activity that environment; common core: the desire to detect we must all engage in. The other 2. Learn from the best practices of and correct errors. trouble comes with reconciling our others (benchmarking);
Volume 68 • No. 2• Spring 2008 9 3. Learn from past experience; mental models. What we can see on holds the key to changing the 4. Experiment with new the outside is individual behavior. world. One of the common themes approaches; of “human factors” (Dekker 2006, 5. Encourage systematic problem The intersubjective world of groups Reason 1997), high reliability solving; and of people is their culture and (Weick and Sutcliffe 2001), and 6. Transfer knowledge throughout shared values. This manifests in the organizational learning (Senge the organization. world as systems and processes. 1994, Garvin 2000) is moving away from focusing on individual behav So far, I’ve talked about the human The exterior is what we can readily ior and focusing more attention on factors work of Dekker (2006) and see and measure. The watchwords systems and processes. Reason (1997), the High Reliability for the exterior column are “what Organizing work of Weick and gets measured gets done.” These There is increasing recognition of Sutcliffe (2001), and the organi are the quadrants of concrete deci the importance of the lower left zational learning work of Senge sionmaking. quadrant of culture and shared val (1994) and Garvin (2000). How do ues. The fire suppression doctrine we begin to make sense of these is an effort to articulate the basic concepts? Are they competing Fire suppression principles and shared values that against each other or do they some doctrine is an effort drive our systems and processes. Ed how fit together? To answer these to articulate the basic Schein (1999, 2004) presents some questions, I find it helpful to turn of the most scholarly work on cul to the integral philosophy of Ken principles and shared ture change. According to Schein, Wilber (2000). values that drive our there are three levels of culture: systems and processes. Integral Perspective 1. Just beneath the surface are One way of looking at the world Artifacts, the visible organiza We can’t see what’s going on inside is to make a distinction between tional structures and processes; a person or a group of people. The what’s inside and what’s outside, as 2. A little deeper lies Espoused watchwords for the interior column well as make a distinction between Values, the strategies, goals, and are Einstein’s famous quip, “Not an individual and a group of indi philosophies (espoused justifica everything that can be counted viduals. When we combine the tions); and counts, and not everything that interior and the exterior with the 3. Deep beneath the surface are counts can be counted.” These are individual and the collective, we get Basic Underlying Assumptions, the quadrants of individual and col Wilber’s (2000) four quadrants or the unconscious, taken-for lective sensemaking. perspectives (fig. 1). granted beliefs, perceptions, thoughts, and feelings (ultimate All four quadrants are important What goes on inside the individual source of values and action). and necessary. One thing to watch is how he or she makes personal out for is what Wilber (2000) calls meaning. This upper left quadrant Because the intersubjective world “monological madness”—thinking includes situational awareness and of our culture can’t be seen, we that one, and only one, quadrant access it through storytelling (Denning 2005) and conversation Figure 1. (Isaacs 1999). Interior Exterior Summary Ever since the first wildland fire Individual Personal Meaning Individual Behavior fighter’s human factors workshop (Putnam 1996) back in June of Collective Culture and Shared Systems and 1995, the fire community has been Values Processes moving away from the “old view
of human error.” For some, it may ➤ seem like a long, slow, tough jour Sensemaking ——➤ Decisionmaking ney—but progress is being made.
Fire Management Today 10 Today, with the increased focus of Dekker, S. 2006. The field guide to under 26-28 April. Fairfax, VA: The International attention on human factors, high standing human error. Burlington, VT: Association of Wildland Fire. Ashgate Publishing. reliability, organizational learning, Schein, E.H. 2004. Organizational culture just culture, doctrine (principle Denning, S. 2005. The leader’s guide to and leadership. (3rd ed). San Francisco, centered leadership), and adaptive storytelling. San Francisco: Jossey-Bass CA: Jossey-Bass Publishers. Publishers. leadership, the interagency wild- Schein, E.H. 1999. The corporate culture land fire management commu Garvin, D.A. 2000. Learning in action. survival guide: Sense and nonsense nity is helping lead the world to a Boston, MA: Harvard Business School about culture change. San Francisco, CA: paradigm shift in the way we think Press. Jossey-Bass Publishers. about safe operations and risk man Isaacs, W. 1999. Dialogue and the art Schön, D.A. 1983. The reflective practitio agement. of thinking together. New York, NY: ner: How professionals think in action. Currency. New York, NY: Basic Books.
These are not isolated and discon McGregor, D. 1985. The human side of Senge, P.M. 1994. The fifth discipline: The nected concepts competing for enterprise: 25th Anniversary Printing. art and practice of the learning organiza our limited attention. These ideas New York, NY: McGraw-Hill Publishing. tion. New York, NY: Currency. weave together into a new tapes Putnam, T. (ed.). 1996. Findings from the Snook, S.A. 2000. Friendly fire: The acci try of how we make sense of the wildland firefighters human factors work dental shootdown of U.S. Black Hawks emerging world of fire manage shop. Missoula, MT: Missoula Technology over Northern Iraq. Princeton, NJ: and Development Center. Report Princeton University Press. ment in the 21st century to assist 9551-2855-MTDC. us in improving safety, reducing Weick, K.E.; Putnam T. 2006. Organizing costs, and restoring fire-adapted Reason, J. 1997. Managing the risks of for mindfulness: Eastern wisdom ecosystems. organizational accidents. Burlington, MA: and western knowledge. Journal of Ashgate Publishing. Management Inquiry 15(3):275-287: Ann Arbor, MI: Sage Publishing Company. References Saveland, J. 2005. Integral leadership and signal detection for high reliability orga Weick, K.E.;. Sutcliffe K.M. 2001. Managing Collins, J. 2001. Good to great: Why some nizing and learning. IN: Butler, B.W. and the unexpected. San Francisco, CA: companies make the leap…and oth others. (eds). Wildland firefighter safety Jossey-Bass Publishers. ers don’t. New York, NY: Harper Collins summit-human factors; Missoula, MT, Publishing.
Web Sites on Fire* The Tea Kettle Ecosystem Experiment!
TA critical question in the Sierra ning fuels treatments on mixed- response to fuels treatments. Nevada forests of California is how conifer forests. Free copies of a DVD summariz to use disturbances effectively to ing the experiments’ results “The restore ecosystems following a The study provides an impor Teakettle Experiment: Fire and century of fire suppression. tant contrast of how the type and Forest Health” can be ordered at intensity of disturbance (including the Web site. The DVD has a com This Web site and its free DVD different levels of thinning) affect bination of six films, publications describe the different ecological forest functions and succession. in PDF format, and Web resources effects of applying fire and thin By measuring more than a dozen with information about restoring ecosystem components, including forest ‘health’ in fire-suppressed * Occasionally, Fire Management Today briefly vegetation, soil, microclimate, car forests. describes Web sites brought to our attention by the wildland fire community. Readers should not construe bon, invertebrates, food webs, small the description of these sites as in any way exhaustive mammals, and tree response vari Found at
Volume 68 • No. 2• Spring 2008 11 th e ge n e s i s a n d ev o l U t i o n o F hi g h reliaBility or g a n i z i n g Michael DeGrosky
he wildland fire community Weick and Sutcliffe discovered the High Reliability For more than 20 Most people in the wildland fire T Organizing concept relatively years, a small but field know about High Reliability recently. Despite its somewhat diverse group of Organizing from the reading the recent introduction to the wildland organizational experts work of Karl Weick and Kathleen fire industry, it is not a new con Sutcliffe of the University of cept. have researched the Michigan’s Ross School of Business nature of what we have and their book Managing the It’s just new to us in the wildland come to call HROs. Unexpected: Assuring High fire community. Performance in an Age of Complexity (2001). High Reliability teach this organizing model to oth ers in the wildland fire community. Organizing—Not A New Weick introduced High Reliability Concept HRO advocates strive to inform Organizing to wildland fire per For more than 20 years, a small and influence opinion shapers and sonnel during the 1995 Wildland but diverse group of organiza decisionmakers who have too often Firefighters Human Factors tional experts have researched the been bombarded with manage Workshop hosted by the Forest nature of what we have come to ment approaches that pass like Service’s Missoula Technology and call a High Reliability Organization thunderstorms—a lot of noise with Development Center. Thus, High (HRO). The HRO theory builds on little significant change. As a result, Reliability Organizing figured and extends organizational research those advocating an HRO orienta prominently in the birth of the conducted since the late 1940s. Our tion must confront and overcome human factors movement in wild- understanding of these origins will the hurdle of skepticism when land fire. remain important as the wildland hesitant managers—and suspicious fire community becomes gener firefighters—assume that they are In the ensuing years, Weick, along ally familiar with High Reliability merely hearing about the latest with associate Sutcliffe, have signif Organizing concepts—and as advo management fad. icantly contributed to understand cates work to provide an HRO with ing High Reliability Organizing traction among wildland fire prac Those who believe that High among wildland fire personnel. titioners. Reliability Organizing represents However, the High Reliability a relevant concept for wildland Organizing concept and the Understanding the genesis of HROs fire organizations will find that to groundbreaking research originated remains particularly important not convince leaders in the wildland in the 1980s with a group of schol only to those advocating the con fire community, they must first ars (Karlene Roberts, Gene Rochlin, cept, but to anyone intending to help them understand the well- and Todd La Porte), University researched nature of an HRO. of California (UC) Berkley.
Michael DeGrosky is chief executive offi cer of the Guidance Group, a consulting Those advocating an HRO orientation must organization specializing in the human and organizational aspects of the wildland confront and overcome the hurdle of skepticism fire services, and is an adjunct instructor in leadership studies for Fort Hays State when hesitant managers—and suspicious University. DeGrosky is also a 30-year wild- firefighters—assume that they are hearing about land fire services veteran and maintains his qualifications as an operations section the latest management fad. chief and type 3 incident commander.
Fire Management Today 12 Roberts’ from the 1993 book New The High Reliability Organizing concept and the Challenges to Understanding groundbreaking research originated in the Organizations summarizes much of the seminal research contributing 1980s with a group of scholars from the to the High Reliability Organizing University of California, Berkley. theory.
Discovering Resilience Roberts, Rochlin, and LaPorte The Future In the process of extending exist originally examined three organiza There's no question that High ing organizational behavior tions: Reliability Organizing provides research, the UC Berkeley research wildland fire organizations with a ers “discovered” High Reliability • The Diablo Canyon nuclear reac very relevant tool. Let’s hope that Organizing already existing in orga tor, as we strive to convince leaders nizations rather than, as one might • The Federal Aviation in the wildland fire community, suspect, purposefully creating a Administration’s air traffic con that they will embrace the well- HRO as a management system. trol system, and researched nature of an HRO and
• The U.S. Navy’s nuclear aircraft recognize its enormous potential in As discovered by these pioneering carriers. our work. researchers, a subset of exceptional organizations managed their work All three organizations struck the References scholars as being unique. While according to principles that they Gary, L. 2003. Tested by fire: What high- held in common. Presumably, they operated in high-risk environ reliability organizations know. Harvard some error-resilient organizations ments similar to other organiza Management Update [serial online]; tions in the research literature 8(12): 3–5.
Volume 68 • No. 2• Spring 2008 13 or g a n i z i n g F o r hi g h e r reliaBility: le s s o n s le a r n e d F r o M Wi l d l a n d Fi r e F i g h t e r s Karl E. Weick and Kathleen M. Sutcliffe
he late wildland firefighter construct a story that explains the In this article for Fire Management Paul Gleason had it right when flame heights and speed of spread Today, we comment briefly on six T he said, “If I make a decision, within the context of that briefing. themes that stand out in those it is a possession. I take pride in it; discussions. Three themes, normal I tend to defend it and not to listen But sometimes the pieces don’t fit. izing, complexity, and failure reaf to those who question it. If I make firm properties originally associated sense then this is more dynamic When this happens, we tend to with High Reliability Organizations and I listen and I can change it. A overlook the significance of this (HROs). The other three themes, decision is something you polish. “poor fit” and mindlessly retain the resilience, brutal audits, and updat Sensemaking is a direction for the frame and the story that we started ing, represent modifications of next period.” with. We don’t keep updating our some original conclusions. We con understanding. Instead, we keep tinue to be struck by the relevance The reason Gleason had it right is the frame rather than question it, of High Reliability Organizing for that his preference for sensemaking ignoring things that don’t fit the the wildland fire community as well encourages listening, questioning, frame—or we let disagreements as the importance of further oppor updating, and directing—all of persist unresolved. This pattern of tunities to learn about the nature which help people adapt to changes selective sensemaking is precisely of this relevance. in fire behavior and crew behav what the principles of the High ior. Mindful management of the Reliability Organizing discourage. Reaffirmed Reliability unexpected is about learning and Themes sensemaking in the face of ambigu Mindful management 1. Mindful organizing lies at the ity and threat. We make sense by heart of reliable functioning. imposing some frame of reference of the unexpected is Managing the unexpected is about and then interpret the bits and about learning and curbing the temptation to treat pieces we see as a plausible story sensemaking in the face unexpected events as normal, and within that frame of reference. of ambiguity and threat. then dealing with the consequences when you fail to curb that tempta For example, we use the morning tion. Mindful action means that briefing as a frame of reference The wisdom of Gleason’s observa you pay close attention to small, and, once we’re on the line, we tion has been apparent to us as early failures so that you can cor Dr. Karl Weick and Dr. Kathleen Sutcliffe we have discussed high reliability rect them while they still can be are internationally recognized experts on principles with members of the corrected. “Even with wide safety High Reliability Organizing. Authors of the wildland fire community during margins and detailed operating new Managing the Unexpected—Resilient workshops, staff rides, interviews, procedures, missteps, missing Performance in an Age of Uncertainty and their earlier edition Managing the and field observations. resources, miscommunications, or Unexpected—Assuring High Performance mistakes have to be found and put in an Age of Complexity, they have been On the basis of those discussions, right before they can turn into a working with the wildland fire com munity for several years. Weick is the we have fine-tuned our understand tragic flaw” (Perin 2006). In HROs, Rensis Likert Distinguished University ing of how groups organize for the big issue is how long a problem Professor of Organizational Behavior and high reliability. The fine-tuning lasts. “The longer problematic con Psychology and Sutcliffe is the Gilbert and Ruth Whitaker Professor of Business is evident if you compare the first ditions persist, the less predictable Administration at the University of and second editions of our book and controllable system interac Michigan, Ross School of Business. Managing the Unexpected. tions become” (Perin 2006). The
Fire Management Today 14 earlier you catch a discrepancy, the following checklists, and pushing links among complexity ratings, more options you have to deal with decisions up the chain-of-com resources deployed and on standby, it. But the earlier you try to catch mand. and having contingency plans. If an error, the harder it is to spot it. simplifications lead to misspecifica 2. Complexity is inherent in reli tion of any one of those elements, HROs are not error-free, but errors able organizing. Wildland fires of brutal audits are likely. don’t disable them. HROs don’t any type are complex events. As the necessarily discover discrepancies Cerro Grande Board of Inquiry said, Here is an example of a misspecifi more quickly, but when they do “Because of the potential for unin cation in the making. A fire man spot discrepancies, they understand tended consequences, prescribed ager talking about a soaring quota their meaning more fully and can fire is one of the highest risk activi for acres to be burned said, “I know deal with them with greater confi ties land management agencies what complexity I want to get when dence. These capabilities seem to be undertake. Contingency planning, I write my burn plans because I enhanced when people create prac which includes identifying neces know how many acres I have to tices and ways of working that: sary resources should a planned burn.” Lower rated complexity ignition exceed prescription param means more acres burned, but it • Track small failures, eters, is an essential component also means more vulnerability if • Resist oversimplification, of a burn plan” (National Park those ratings ignore on-the-ground • Remain sensitive to operations, Service 2000). To deal with this conditions. • Maintain capabilities for resil complexity, HROs are guided by a ience, and reluctance to simplify views of the Complexity is not a problem • Take advantage of shifting loca world. They hesitate to live by gen unique to the world of firefight tions of expertise. eralizations and generic categories ing. Everyone makes assumptions because they know that it takes a about how complex a project will Specifically, when people follow complex mental picture to register be, what resources are needed to these five principles of mindful a complex event. They work hard to complete the project, and how to organizing, they weaken tendencies complicate their views in order to avoid entrapment. Those assump to: register differences between present tions can be rough or nuanced. situations and past experience more Resilience lies in the direction of • Look solely for confirmation of fully. nuance. their hunches, • Develop tunnel vision under pres When you organize, you simplify. 3. Preoccupation with failure sure, But you don’t need to simplify equals preoccupation with learn • Misunderstand and misestimate casually, habitually, or instantly. ing. Preoccupation with failure, the the complexity of events, You can be more deliberate in your first HRO principle, captures the • Treat unexpected deviations as choices of what to simplify. To be need for continuous attention to normal, more deliberate means to be more details by detecting small discrep • Blame others for errors, thorough in articulating mistakes ancies that could be symptoms of • Discount worst case scenarios, that you don’t want to make. In larger problems in a system. HROs and the case of prescribed burns, one watch for early warning signals • Underestimate the rate of change. mistake you don’t want to make is because they know that they have to misjudge the complexity of the neither experienced all ways in If these tendencies go unchecked burn. As the Cerro Grande Board which a system can fail nor have they can lead to unreliable perfor of Inquiry noted, there are strong they imagined and deduced all pos mance, escaped fires, injuries, and sible modes of failure. This first fatalities. Efforts to reverse these principle tends to be the one that tendencies are much harder than The pattern of selective firefighters find most objectionable. they look. They’re hard because—to sensemaking is precisely When they hear this guideline, fire organize mindfully—you have to what HRO principles fighters think that they are being forgo the “pleasures” of attending discourage. encouraged to find fault with other to success, simplifying, planning, people, ignore their successes,
Volume 68 • No. 2• Spring 2008 15 search for bad news, or become small emerging failures because • “Didn’t we just learn something vulnerable to career setbacks when these might be clues to additional from those fatalities at South they admit screw-ups. failures elsewhere in the system. Canyon?” Second, HROs anticipate and Firefighters also worry about the specify significant mistakes that In each of these cases, people are amount of effort it takes to look for they don’t want to make. In both paying attention to two things: failure day in and day out. As one cases, the preoccupation is war small, early clues that something is firefighter put it, “If every day we ranted because the chain of events not right and the potential mistakes have to assume that we’ve missed that produce failures can wind deep that they don’t want to make. something, then it is a real struggle into the organization and be hard to think that way.” Objections to spot. It takes more than atten Paying attention to the mistakes such as these miss some important tiveness to what is going well if you you don’t want to make is a hall points. want to stay on top of the complex mark of high reliability. In fact, ity. research shows that the major First, reliable performance is determinant of reliability in an defined relative to failure. Third, a group’s knowledge of a sit organization is not that it values uation, environment, and the group reliability or safety more than other Reliability refers to “what one can itself is incomplete. HROs recog organizational values, but that it count on not to fail while doing nize failure based on the existence strongly disapproves of incorrectly what is expected of it.” The role of of those knowledge gaps. specifying, misestimating, and mis failure in reliable performance can understanding. be specified by three questions: Those who object to a preoccupa tion with failure often are acting in Saying “Be safe” is not enough. • What do people count on? ways that exemplify this principle. When more members of an organi • What do people expect from the zation care about incorrectly speci things they count on? Consider these actions described by fying, misestimating, and misun • In what ways can the things peo fire managers: derstanding, the organization can ple count on fail? attain higher reliability (Schulman • “After I get briefed on Lookouts, 2004). The answers to these three ques Communications, Escape Routes, tions provide clues about what it is and Safety Zones (LCES), I go Modified Reliability that could go wrong and what it is walk the escape route for myself, Themes that you don’t want to go wrong. time the walk, and examine the Mindful Organizing Requires The key word in all three questions size of the safety zone.” Resilient Performance is what one can count on, not who. • “We work hard to describe the In the first edition of Managing worst case scenario, watch for the Unexpected, the subtitle reads Reliable performance is a system signs that it is beginning to hap Assured Performance in an Age of issue, not an individual issue. pen, and hope for the best.” Complexity. In the second edition,
Failures are connected. Small early • “We need to think about what the subtitle has been changed to failures steer subsequent events could go wrong when we move Resilient Performance in an Age of toward outcomes that no one into that area with all of those Uncertainty. Why the change from expected. trees blown down.” “assured” to “resilient” and from
• “If we cross this draw, do you “complexity” to “uncertainty?” HROs are preoccupied with failure know how many 10 and 18 we in three ways. First, they detect break?” Think about the following state ment: “A safety zone is just a hypothesis.” That statement means that however reassuring a LCES The wisdom of Paul Gleason’s observation was structure might be, it still has apparent as we discussed HRO principles with uncertainties and requires adjust members of the wildland fire community. ments, improvisation, and resil ience to provide the protection
Fire Management Today 16 Managing the disruptive events—as the system everything that was left unprepared unexpected is about becomes better able to absorb a becomes a complex problem, and surprise and stretch rather than every weakness comes rushing to curbing the temptation collapse, the “brutality” of an the forefront” (Lagadec 1993). to treat unexpected audit decreases; and events as normal, and • Learn and grow from episodes of In the ensuing years, we have then dealing with the resilient action. come to see the idea of a brutal consequences when audit as a central factor in resilient These adjustments are pos performance. In the revised edi you fail to curb that sible because of large and varied tion, the very first sentence reads, temptation. response repertoires, competence “Unexpected events often audit our in reassembling existing practices resilience.” into new combinations, intense expected. In an age of uncertainty, sharing of information, and a well- Brutal audits are common in wild- it’s hard to anticipate specifics and developed ability to maintain emo land firefighting. An entrapment is prepare for them. Therefore, you tional control during chaos. an example of a brutal audit, as are need generalized resources. As lousy briefings, poor maps, dated crewleaders often say, “be prepared Although people prefer to antici weather forecasts, inexperienced for anything.” pate trouble and plan their defenses managers, etc. When entrapment in advance, it’s difficult when there and other events occur, people In any setting where people strive is uncertainty. As Aaron Wildavsky under pressure often fall back for higher reliability, they never explains, “Where risks are highly on old habits and routines (self achieve perfection. That’s because predictable and verifiable, and interest, familiar roles, overlearned “human fallibility is like gravity, remedies are relatively safe, antici personal tendencies, and flight) weather, and terrain—just another pation makes sense; most vac that are less suited to the current foreseeable hazard” (Wildavsky cines fit this criterion of efficient circumstances. Doing so can make 1991). If errors are inevitable, man anticipation. Where risks are highly a situation worse. agers need to be just as concerned uncertain and speculative, and rem with the cure as they are with edies do harm, however, resilience When people are put under pres prevention. To be resilient is to be makes more sense because we can sure, they tend to act like they did aware of errors that have already not know which possible risks will in their previous role. For example, occurred and to correct them actually become manifest” (1991). recently promoted crewleaders before they worsen and cause more revert to squad boss behavior. The serious harm. When you manage When managers face uncertainty, reason this principle has become the unexpected, you’re playing their goals are to lower the magni more crucial is that with more catch up by facing something that tude of the disruption by catching shuffling of personnel among has happened but was not antici it early and speed up the resump crews, more temporary assign pated. tion of the activity that was under ments, more training compressed way before the disruption. into less time, and more regula Despite the best-laid plans, unex tions to keep track of there is less pected events often force organi Brutal Audits: An Enduring Threat complete learning of newer skills zations to be reactive rather than In the first edition of Managing the and less time spent building close proactive. Resilient reacting occurs Unexpected, just two pages before ties. The result is a weakened team when a system stretches and then the end of the book, we included with much left unprepared. Under returns to something resem Pat Lagadec’s description of a bru pressure, when it is important bling its former shape. Resilience tal audit that reads, “The ability to to see clearly what is happening, involves the ability to: deal with a crisis situation is largely alertness falters and small errors dependent on the structures that become large. • Absorb strain and preserve func have been developed before chaos tioning despite the presence of arrives. The event can in some ways Brutal audits are a harsh reminder adversity; be considered as an abrupt and that safe functioning is not bank • Recover or bounce back from brutal audit: at a moment’s notice, able (Shulman 1993). Just because
Volume 68 • No. 2• Spring 2008 17 an incident management team or 12 miles (22 km) southwest of People should train crew were able to hold it together Enterprise, fire managers decided for safe functioning, yesterday doesn’t mean that they’ll to manage two of these ignitions as then practice and hold it together today. Teams have wildland fire use (WFU) events. to work on strengthening their perform it—essentially, coordination, communication, and As then-Dixie National Forest fire over learning those trust every day. They never solve management officer Brett Fay practices. the problems of reliability and resil recalls, “We expected the fire would ience once and for all. Instead, they burn around 7,000 acres (2,800 have to train for safe functioning, ha); we didn’t expect it would get WFU was declared a suppression practice it, build it into their prac so big.” They also didn’t expect that fire. After the decision was made, tices, and overlearn those practices. the fire would uncharacteristically Patti Koppenol, the Intermountain change direction multiple times, Region’s deputy regional fire direc Continuous Updating To Reduce grow so fast, cross a dirt road tor, claims she “heard a collective Uncertainty boundary, or generate so much sigh of relief as though people thought we had finally come to our Mindful organizing is sensitive to smoke that the town’s residents senses.” impermanence and change. Failing would need to be evacuated. Nor to register ongoing variation and did they expect that the (suppres Contrast this pattern of continu change is a symptom that alertness sion) water source that they had ous updating with the less frequent is waning. This is one reason why counted on would be unavailable. updating at the Cerro Grande pre blind adherence to plans is danger scribed burn, which resulted in $1 ous. Surprises kept cropping up, but every time a new surprise surfaced, billion of damage in May 2000. The crew that lit the fire expected that To see how updating can reduce managers updated their under their burn plan was doable and met uncertainty, consider how manag standing of events. They weren’t objectives, that the fire itself would ers dealt with the Hawkins wild- afraid to ask for help or admit that be of low to moderate complexity, land use fire in the Dixie National they were in trouble. As a result, on that they had a capable crew and Forest (Keller and Fay 2005). This the third fire day, after 12,500 acres resources, that the dispatch system fire burned more than 35,000 acres (4,800 ha) had burned, the Hawkins (14,000 ha) and threatened the town of Enterprise in southern Utah.
Fire agencies and local ranch ers had been meeting for years to discuss concerns about the area’s overgrown vegetation and had agreed to conduct a prescribed burn. Before fire managers could light the planned fire, nature did it for them. When a series of light ning strikes started several small wildland fires in late July 2004,
Paying attention to mistakes that you don’t want to make is a key hallmark of high Karl Weick and Kathleen Sutcliffe on the Cerro Grande Staff Ride during the first reliability. Managing the Unexpected Workshop held in Santa Fe, NM. Photo: Tom Iraci, Forest Service, 2004.
Fire Management Today 18 was reliable and responsive, that tion they had prior to the burn” Organizing for high reliability is contingency resources were on (National Park Service 2001). It is about acting in ways that keep sen standby, that weather forecasts did the information during the burn semaking focused on the present not preclude burning, and that they that was more critical. Systems that conditions, on threats before they were at a preparedness level that mismanage the unexpected tend to get uncontrollable, and on quick made burning possible. ignore small failures, accept simple recovery from interruptions. diagnoses, take frontline operations The very fact that so much of the for granted, neglect capabilities for References success of this project was tied to resilience, and defer to authorities Keller P. and Fay B. 2005. Hawkins wild- these expectations suggests the rather than experts. Fragments of land fire use staff ride preliminary study: Staff ride information and advance study need for continuous updating to this pattern remain visible in Cerro packet for the Hawkins fire use staff ride. see if expectations were being ful Grande. Enterprise, UT: Dixie National Forest filled and to catch early indications (sponsored by Region 4 Fire and Aviation that they weren’t. The Core of Mindful Management Program). Organizing Lagadec, P. 1993. Preventing chaos in a That updating happened more Mindful organizing is about listen crisis: Strategies for prevention, control, slowly than did changes in what and damage limitations. London, UK: ing, asking questions, and tak McGraw-Hill International: 54. they faced. As a result, they were ing action to better understand a slow to adjust to such things as a developing story. This is the core National Park Service. 2000. Cerro Grande prescribed fire investigation report. May burn that was more complex than of the resilient sensemaking that anticipated, a blackline whose inner 4-8. Boise, ID: National Interagency Fire Paul Gleason practiced. A team that Center edge was hard to extinguish, loss talks, asks questions, and thinks National Park Service. 2001. Cerro Grande of a crew due to exhaustion just 4 while acting is better able to iden hours after the burn started, uncer prescribed fire, board of inquiry, final tify: report: Sante Fe, NM: 14. tainty about whether a standby crew would be provided and how • Large threats in the making, Perin, C. 2006. Shouldering risks: The soon, conflict about budget issues, culture of control in the nuclear power • Oversimplification, industry. Princeton, NJ: Princeton and an exhausted holding crew. • Attention that is distracted from University Press: 203-204. current operations, Schulman, P. 1993. The negotiated order of The leadership at Cerro Grande did • Excess attention to anticipation less updating than did the leader organizational reliability. Administration at the expense of resilience, and and Society. 25: 353-372. ship at the Hawkins Fire. The Cerro • Deference to authority rather Schulman, P. 2004. General attributes of Grande Board of Inquiry implied than to people with expertise. a similar assessment: it described safe organizations, quality, and safety in health care. Oakland, CA: 13/Supplement judgments at Cerro Grande as “not We all try to make sense. II. BMJ Publishing Group Ltd & Institute arbitrary, capricious, or unrea for Healthcare Improvement. sonable in light of the informa Wildavsky, A. 1991. Searching for safety. New Brunswick, NJ: Transaction: 221.
Volume 68 • No. 2• Spring 2008 19 th e ce r r o gr a n d e pr e s c r i B e d Fi r e es c a p e Me e t s t h e Fi r s t Ma n a g i n g t h e Un e x p e c t e d Wo r k s h o p Paul Keller
ack in May 2000 when I first heard the news about the No doubt about it, I wanted to assign blame. now infamous Cerro Grande B Somebody, I truly believed, had to step up, admit prescribed fire escape—mostly through the scream of national to, and be held responsible. headlines—I immediately thought: Who messed-up? this inexcusable disaster. People, he Workshop would set the tone for a assured, would definitely be held subsequent ongoing annual series No doubt about it, I wanted to accountable and punished. of these special hands-on organiza assign blame. Somebody, I truly tional learning conferences featured believed, had to step up, admit to, I’m sure that, back then, I privately in different parts of the country and be held responsible. thought: Good! (see sidebar).
My coworkers—even though we That was before I had experienced Four years after the Cerro Grande were all hundreds of miles away the first national wildland fire Fire and after several people’s from the smoke—not to men community-tailored Managing the careers had careened into night tion the pertinent details—felt the Unexpected Workshop on High mares, I attended this inaugural same. Unfortunately, so did the Reliability Organizing. Little did May 2004 event hosted by the system. I know then, I had a lot to learn Wildland Fire Lessons Learned about organizing, organizations, Center. This unique high reliability That following Sunday—after and blame. learning session’s focal point was 18,000 people had been evacu an all-day staff ride* to the actual ated and 235 homes had fallen to They Eagerly Came Cerro Grande prescribed fire site**. the flames in nearby Los Alamos and surrounding communities—I How can we organize for high per formance in a setting where the The four primary members of remember watching a morning Bandelier National Monument’s news program. The well-known potential for error and disaster can be overwhelming? In doing so, how Cerro Grande prescribed burn crew, television reporter was pressing the including the unit’s then-fire man Secretary of the Interior to reveal can we best apply High Reliability Organizing concepts into the pre agement officer, agreed to return what exactly was going to befall and participate in this event. the person or persons responsible scribed fire and fire use arenas? for this calamity. The Interior These questions and others encom In the immediate aftermath of Secretary duly retorted that they the Cerro Grande escape, all of were launching an official investi passed the key underlying themes that wove through that first week- these employees had been abruptly gation and would know within the removed and transferred from their week just who was to blame for long Managing the Unexpected in Prescribed Fire and Fire Use * For more information on the staff ride learning tool Paul Keller served as managing editor of Operations, A Workshop on High concept, see Fire Management Today Issue 62 Volume Fire Management Today from June 2005 Reliability Organizing event. This 4 on the Dude Fire Staff Ride or the Fire Management to June 2007. A former hotshot firefighter Today Issue 66 Volume 2 article “Staff Ride to the Battle innovative week beckoned nearly of Little Bighorn and Mann Gulch Fire.” and newspaper editor and publisher, he works as a technical writer-editor for the 100 members from the ranks of **This prescribed fire was originally known as the Wildland Fire Lessons Learned Center the national interagency wildland Upper Frijoles Units 1 and 5 Prescribed Burn. Because and for the Forest Service’s National Fire it was implemented on Cerro Grande peak, and its fire community to Santa Fe, NM. subsequent escape was named the Cerro Grande Fire, Systems Research and Fire and Aviation This first Managing the Unexpected the burn is now commonly referred to as the "Cerro Management programs. Grande" prescribed fire.
Fire Management Today 20 Annual Workshops Introduce High Reliability Organizing Concepts A total of three national Managing the Unexpected in Prescribed Fire and Fire Use Workshops have been host ed by the Wildland Fire Lessons Learned Center:
• The May 2004 event in Santa Fe, NM, with the field study staff ride of the Cerro Grande prescribed fire escape. • In February 2005, the second workshop held in Jacksonville, FL, featured a field study of the Okefenokee Ecosystem Fuels Management Program. • In May 2006, the Managing the Unexpected Workshop convened in Missoula, MT, that highlighted an onsite staff ride to the I-90/Tarkio Fire shelter deployment site.
The purpose of all three workshops was to introduce participants to the principles of High Reliability Organizing using key ideas developed by Dr. Karl Weick and Dr. Kathleen Sutcliffe. The workshops’ common, overall goal was to help facilitate new knowledge and tools—workable methods—for implementing High Reliability Organizing back on participants’ home units.
The Wildland Fire Lessons Learned Center is now developing a curriculum on high reliability designed to help build wildland fire programs that are consistently successful in achieving their fire management objec tives safely and effectively. The center is achieving this through a special cadre of wildland fire employees who are teaching people to facilitate High Reliability Organizing techniques on their home units. (For more information, see article on page 35).
The written reports and video/DVD productions from all three of the national Managing the Unexpected Workshops are available through the Wildland Fire Lessons Learned Center at
jobs at Bandelier. Their offices had wildland fire-savvy audience. And tive “sensemaking” under pressure, literally been raided by Federal law yet, they eagerly came. and handoffs in extreme events. enforcement agents. Their files and records were taken—and never Overarching Theme Sutcliffe is the Gilbert and Ruth returned. Even more devastating, The concept and practice of High Whitaker Professor of Business their lives were locked into the Reliability Organizing served Administration at the University of crosshairs of a seemingly never- as the overarching theme of Michigan, Ross School of Business. ending onslaught of official inqui this Managing the Unexpected ries, reviews, and investigations Workshop. University of Michigan Her research is devoted to High that dragged on and on for almost professors Dr. Karl Weick and Dr. Reliability Organizing and under- 12 long months. Kathleen Sutcliffe, internationally recognized experts and authors on These four people’s charge at the this subject, served as the work Managing the Unexpected Staff shop’s central presenters. Ride was to come back and explain how and why they had planned and Weick is the Rensis Likert implemented this landscape-scale Distinguished University Professor burn that would forever alter their of Organizational Behavior and lives. They knew that every step Psychology at the University of of the way on that staff ride, they Michigan, Ross School of Business, would be subjected to questions whose research interests include Kathleen Sutcliffe at the first Managing and second-guessing from an astute high-reliability performance, collec the Unexpected Workshop held in Sante Fe, NM. Photo: Tom Iraci, Forest Service, 2004.
Volume 68 • No. 2• Spring 2008 21 The concept and practice of High Reliability • A set of organizing practices that Organizing served as the overarching theme of the can lead to more reliable and effective work, especially under Managing the Unexpected workshop. trying work conditions; • A mindset that can help us catch and correct mistaken or misinter standing the fundamental mecha thought-provoking book Managing preted actions; nisms of organizational adaptation, the Unexpected–Assuring High • A system for better understand reliability, and resilience. Performance in an Age of ing organizing practices that can Complexity. This dynamic duo is increase our awareness of small As we quickly learned that week, universally heralded for helping mistakes that can grow into large both of these individuals are develop the concepts that support crises; and approachable, personal human High Reliability Organizing. They • Examples of what occurs when beings who exude a sincere interest were in attendance at the workshop people and systems give high or in helping the wildfire fire environ all week and also experienced the low priority to High Reliability ment become a safer place to be. staff ride. “We had the opportunity Organizing principles. to clarify ideas, answer questions, These two distinguished research and learn,” Weick observed at Blame and Punishment ers and thought-leaders on orga week’s end. nizational concepts and strategies “Karl Weick and Jim Reason, with examine organizations—High High Reliability his ‘Just Culture’ concept, have Reliability Organizations (HROs)— Organizing taught us that an organization is that must manage unexpected defined by how it handles blame “The key definition of High threats and, therefore, can’t afford and punishment,” pointed out Mike Reliability,” Sutcliffe explained to to make mistakes. These work envi DeGrosky, lead facilitator at the us, “is working in an environment ronments include flight deck crews workshop. in which both high risk and high on aircraft carriers, nuclear power- effectiveness can coexist.” generation and chemical produc “High Reliability Organizing is a tion plants, air traffic control sys system,” DeGrosky explained. “It “High Reliability Organizing is real tems, hospital emergency depart is all about looking at system-wide ly the glue or foundation for how ments, and the entire wildland fire responsibility. It isn’t just a wild- we operate—and should strive to community. Weick started his long land fire safety tool—it’s about the operate—in wildland fire manage time affiliation with wildland fire entire organization and ment,” said Paula Nasiatka, man fighters at the Wildland Firefighters organizing.” ager of the Wildland Fire Lessons Human Factors Workshop held Learned Center and Managing the in the aftermath of the fatal 1994 As we learned that week in Santa Unexpected Workshop moderator. South Canyon Fire. Fe, part of an HRO’s mindfulness, “It is a way to think logically to means paying attention to “weak better prepare for the unexpected Before the workshop, all partici signals” that things aren’t going events. It is a particularly good pants received Weick and Sutcliffe’s method for making sense—and even foreseeing—the unexpected.” Weick started his Starting on the workshop’s first longtime affiliation with day, through an interactive com wildland firefighters at bination of lecture, discussion, the Wildland Firefighters exercises, and video presentations, Human Factors Weick and Sutcliffe illustrated the principles of an HRO. They also Workshop held in the explained the idea and importance aftermath of the fatal of what they call “mindfulness” as 1994 South Canyon Karl Weick at the first Managing the they introduced us to: Unexpected Workshop held in Sante Fe, Fire. NM. Photo: Tom Iraci, Forest Service, 2004.
Fire Management Today 22 right. We discovered that we all Darkest Chapter in My Life need to interpret these signals as portends of possibly bigger, immi “Coming back here reopens the book on the darkest chapter in nent failures and to take the appro my life. But if my participation here today helps prevent any of priate responsive actions to resolve you from going down the road we did 4 years ago, it will all be and correct these situations before worthwhile.”—Matt Snider they escalate. If we are truly being highly reliable, we are constantly scanning for these weak, telltale signals every day and during all might help prevent any of you What Went Wrong? from ever going through what we operations. As we moved through the vari went through and, two, for (the ous staff ride stands that day, we late) Paul Gleason. Because of his It's oversimplifying to believe observed how these people who had emphasis on learning and teach that one individual's action can implemented the Cerro Grande pre ing, I know he would have wanted not cause large, systemic failures. scribed fire were all genuine profes us to come back here to be a part Consequently, if we simply focus on sionals. They all had extensive expe of this. (Editor’s Note: See Matt punishing an individual, the faulty rience burning in the Cerro Grande Snider’s personal reflections on or flawed programmatic system fuel type. under which this failure occurred is the staff ride and “Managing the Unexpected” in this issue on never truly addressed or corrected. So, what went wrong? page 26. “HROs try to understand the sys temic reasons for why the accident “The staff ride was the key to this happened—rather than focusing on week,” said Dick Bahr, fire use An organization is punishing the individual,” Sutcliffe specialist with the National Park defined by how it confirms. Of course, if criminal Service’s Fire Program Center who handles blame and negligence or serious malfeasance served as co-chair of the work punishment. has occurred, that’s an entirely dif shop’s steering committee. “It got ferent scenario. everybody’s feet on the ground and simultaneously brought Weick Through the vehicle of the staff The Staff Ride and Sutcliffe’s High Reliability Organizing concepts to life.” ride, it became obvious that a col Al King, fire management officer at lective series of unexpected events Bandelier National Monument back helped upset this team’s original in 2001 who functioned as holding operational and contingency plans boss on the Cerro Grande burn, and most likely collectively con served as the lead presenter at the spired to help spawn the eventual staff ride’s first stand. King’s open escape. These unforeseen setbacks ing words were both heartfelt and included: riveting. They set a universal tone for the subsequent flow of organi • The unexpected—for the most zational learning that would perco part, different personnel than late throughout that day. anticipated (from the off-unit holding crew) who appeared At the next stand at the foot of onsite that evening of the burn. prominent Cerro Grande peak, This crew’s members eventually presenter Matt Snider, who had became fatigued and had to pull served as ignition specialist on off the burn’s high-elevation hill the Cerro Grande prescribed fire, after there was fire on it. echoed King’s reasoning. “I came Al King served as the holding boss on • An inability to receive additional, back here today for two reasons,” the Cerro Grande prescribed burn. His necessary resources through Snider confided. “One, I’m hope opening remarks on the staff ride were both heartfelt and riveting. Photo: Tom the dispatch system. Nine hours ful that something I do or say Iraci, Forest Service, 2004. transpired from the first time
Volume 68 • No. 2• Spring 2008 23 verted type 1-managed wildfire that High Reliability eventually burned into Los Alamos Organizing is really a full 4 days after the burn had transitioned from prescribed fire to the glue or foundation wildfire. for how we operate— and should strive to Stimulate Change operate—in wildland fire A primary goal of this first management. Managing the Unexpected “The staff ride was the key to this Workshop was to help ensure that week,” said Dick Bahr, fire use specialist concepts and knowledge absorbed that—nearby—resources were with the National Park Service’s Fire during the week would successfully Program Center who served as co-chair requested through dispatch, until of the workshop’s steering committee. make it back home to participant’s they finally arrived on the pre “It got everybody’s feet on the ground work units to help stimulate per scribed fire. and simultaneously brought Weick and sonal and organizational change. Sutcliffe’s High Reliability Organizing • The helicopter requested to sup concepts to life.” Photo: Tom Iraci, Forest press the problematic slopover Service, 2004. But we all know the customary, ill- area which was located at 10,000 fated scenario. No matter how stim feet (3,045 m), arrived late and als to hear that side—especially ulating a workshop or conference without the necessary suppres presented in a way in which these might be, once we get back home, sion bucket. people can feel safe doing this.” much of our newly acquired insight • “Even though I was on the type and motivation takes second place Integration Phase 1 interagency management team to our daily work demands. “It took a real strength and strong assigned to the Cerro Grande display of courage for these folks Fire, I learned a whole lot more to return here and become so inti about this fire yesterday on the HROs try to understand mately involved in this,” said lead staff ride. What I now know about the systemic reasons staff-ride facilitator Dick Mangan. this prescribed fire—what we for why the accident Mangan’s initial sentiments were learned yesterday—and what the echoed throughout this staff ride investigation reports say, are two happened rather than climax session. Other individual different things. We need to find focusing on punishing comments and observations from a way to set the record straight.” the individual. various workshop participants • “I firmly believe that the whole included: investigation process needs to be revisited. We all know mistakes “That’s why we decided to conclude • “I saw a tremendous display of are going to happen—hopefully the workshop with two nationally resilience by these people who not on this scale. But I’d like recognized organizational psy came here to share their stories to think that when we conduct chologists,” explained workshop with us. I hope their presence these post-event processes—these chair Dave Thomas. “Their facili here was as helpful for them as it investigations and reviews—that tated exercise helped us understand was for me.” we protect our employees and not why there’s a natural immunity to • “Yesterday, one presenter abandon them.” change in all of us. They gave us a expressed how thankful he was proven, hands-on method for over to have an opportunity to tell the Another important concept high coming this resistance.” other side of this event. Certainly, lighted more than once during the considering all the liability that is integration phase regarded our These two “immunity to change” surrounding these folks and their agencies’ collective focus solely experts who worked with workshop agencies, it’s understandable how on the initial Cerro Grande pre participants throughout the event’s he might not want to say a lot. scribed fire escape. This amplified final day were Harvard University But it’s important. It’s important concentration on the burn’s escape Graduate School’s Robert Kegan, to those who were there. And it’s overlooks the fact that it was a con the William and Miriam Meechan important to us as profession
Fire Management Today 24 Professor of Adult Learning and television documentary news pro The staff ride got Professional Development, and grams. The subject was actual hos Lisa Lahey, research director of the pital mistakes. First up was this dis everybody’s feet school’s Change Leadership Group. tressing case of a poor man whose on the ground and diseased right arm was scheduled simultaneously brought Additionally, 20 workshop attendees for amputation. In surgery, they Weick and Sutcliffe’s participated in a 3-month followup mistakenly removed his “good” left High Reliability coaching process with Kegan and arm. Now he would have no arms. Lahey, authors of How the Way The “blame” was assigned to a tech Organizing concepts We Talk Can Change the Way We nician who had—unintentionally— to life. Work. reversed the ex-ray. I knew that if the system focused Personal End Note I was beside myself. How could solely on retribution to this techni When I got back home from Santa someone do such a thing? I started cian, a significant organizational Fe, I felt truly enlightened. No to be consumed with all kinds flaw—the true health of this hos doubt about it. I could feel those of punitive thoughts toward this pital’s overall operational system— new High Reliability Organizing person. That is, until the reasoned might never be addressed. concepts and perceptions bubbling voices of Dr. Karl Weick and Dr. around up there inside my brain. Kathleen Sutcliffe began to seep And I knew that—thanks to the Then, not too long after my return, back into my brain. Wildland Fire Lessons Learned I was watching one of those weekly Center’s Managing the Unexpected I quickly slipped my newly acquired Workshop—I was a little smarter High Reliability Organizing lens than I used to be. "High Reliability over my misplaced reasoning. I Organizations try to under then realized that maybe that tech stand the systemic reasons for References nician is completely overworked. Weick, K.; Sutcliffe, K. 2001. Managing why the accident happened— Or, perhaps this person’s physical the unexpected: Assuring high perfor rather than focusing on pun working environment is the true mance in an age of complexity. University ishing the individual." —Dr. systemic culprit? And what about of Michigan, Ross School of Business Series. San Francisco, CA: Jossey-Bass Kathleen Sutcliffe. the hospital’s presurgical proce Publishers. dures? Kegan, R; Lahey, L. 2001. How the way we talk can change the way we work. Jossey- Bass Publishers.
Volume 68 • No. 2• Spring 2008 25 op e n i n g t h e da r k e s t ch a p t e r o F My pr o F e s s i o n a l ca r e e r Matt Snider
n May of 2000, I was the act provide the foundation for chang ing fire use module leader at ing the way that we think about “Learning from failure is hard.” I Bandelier National Monument our organizations and how we build —Kathleen Sutcliffe, co-author near Los Alamo, NM. them. of Managing the Unexpected– Resilient Performance in an When I reported for duty on the Second Thoughts Age of Uncertainty. Speaking at the 2004 Managing morning of May 4, I was prepared I was asked to participate in the the Unexpected Workshop. to start work on a prescribed fire first Managing the Unexpected that would take most of my time Workshop and to assist with its for the next month or so. I was staff ride presentation to examine completely unprepared, however, our 2000 prescribed fire escape. I at Bandelier who had also helped for the effect that the events of the agreed without giving the decision implement our prescribed fire and next few days would have, both on much thought. planned to attend the workshop my life and on the national wild- and help with the staff ride. land fire management community. But after a couple of days think ing about what I had agreed to, I Honoring Paul Gleason This escape, which would become admit that I was a bit uncertain as Al reminded me of a couple of known as the Cerro Grande Fire, to whether I wanted any part of an things. First, we would be present and its subsequent run through the exercise of this kind. ing to other wildland fire manage- town of Los Alamos and the Los Alamos National Laboratory pre Giving a presentation like this cipitated some profound changes in meant opening the darkest chapter the way that we manage fire on the of my professional career and doing American landscape. so in front of a group of strang ers. I had given testimony to an Four years later, a national work interagency investigation team, a shop sponsored by the Wildland U.S. Government Accountability Fire Lessons Learned Center would Office Investigation, and a Board of Inquiry. I had all my personal effects in my office seized—even Giving a presentation down to training manuals, periodi like this meant opening cals, and old fire photos (to this day the darkest chapter of I have no idea where any of these my professional career. items are). And I’ve told my story to a camera crew and producer from the Public Broadcasting Service. Matt Snider is currently State Fire Program Manager for The Nature Therefore, now, second thoughts Conservancy in Savannah, GA. He began his wildland fire career in 1993 at Zion loomed large—I really didn’t think National Park in Utah, and has worked that I had it in me to go through it for the National Park Service and Forest again. Service on engines, helitack crew, fire use modules, and hotshot crew. As this article explains, in May 2000, Snider was involved After developing a serious case of in the prescribed fire that escaped and “cold feet,” I called Al King, my Photo of Matt Snider on the Cerro Grande eventually became the Cerro Grande Fire former fire management officer Staff Ride. Photo: Tom Iraci, Forest Service, that burned into Los Alamos, NM. 2004.
Fire Management Today 26 I wanted to come back a friend. I wanted to come back I was absolutely amazed at the out to New Mexico to honor Paul’s pouring of support that seemed to to New Mexico as memory and to help myself and fill the room during the staff ride’s a way to honor Paul others become better “students of final integration phase. To listen to Gleason’s memory and fire”—as Paul so often encouraged so many of my peers say that they, to help myself and us to be. too, would have made the same calls, that they appreciated what we others become better With my feet thawed and my half- came to do, and that it was valuable “students of fire.” hour presentation prepared, I for them professionally, was both arrived in Santa Fe. I was immedi gratifying and humbling. ately relieved to run into two ment professionals who would not old friends who made their support Realizing that the worst profes be looking to second guess us in known in no uncertain terms. sional crisis I have ever endured any way. Second, he asked me to would positively contribute to remember that it was very impor For that entire week, I was the improvement of prescribed tant to (the late) Paul Gleason that impressed with the environment fire planning and—in the event our experience on the Cerro Grande that the workshop coordinators, of another such prescribed fire Fire be a learning opportunity for presenters, and attendees created. escape—would hopefully help move the wildland fire community. I never felt second-guessed, even us toward a more “Just Culture,” while our actions and decisions on made my decision to contribute to I had several opportunities to work the prescribed fire were being scru the workshop seem, in hindsight, for and with Paul before the Cerro tinized. like a very easy one. Grande Fire and considered him
Volume 68 • No. 2• Spring 2008 27 ca s e st U d y : is hi g h reliaBility or g a n i z i n g t h e ne x t Be s t th i n g ? yo U de c i d e
Oh no, not another “the latest best thing”...
Brett Fay
n the wildland fire community, it seems like every few months or Many of the High Reliability Organizing I so some new solution—intended processes definitely pack a lot of utility for to remedy all of our problems— gets tossed our way. That’s what I wildland fire managers. first thought about High Reliablility Organizing. The next thing I knew, I was telling my fellow wildland I realized that no process meets But on closer inspection, HRO fire managers that High Reliability all needs, but many of the High principles are not really new at all. Organizing really was the latest Reliability Organizing processes The conscious systemic nature of best thing! definitely pack a lot of utility for High Reliability Organizing might wildland fire managers. be new, but the principles are not. So, what’s going on here? To be culturally pertinent, our So, how do you present HRO prin Is High Reliability Organizing real wildland fire management tools ciples to a group that really doesn’t ly a worthwhile tool for us? Or, is it must also be relevant to the day want another “tool?” just someone else’s good idea that to-day difficulties that confront doesn’t really have any applicable us. Without the good “fit” between What works for me is to first pro traction to our wildland fire man what we actually do and the value vide different examples of effective agement jobs? that any new process provides us, HRO principles that people might that “next best thing” could end up already be doing (without the HRO I was first exposed to High an academic exercise with little or labels) and then connect these Reliability Organizing in 1990 as no application. practices into a mindful organizing part of a larger education on deci process with the principles appro sionmaking theory, organizational Firsthand Experience priately identified. process, and effective teaching From first-hand experience, I know techniques. At first, I was skepti that applying the High Reliability Identifying HRO cal. A High Reliability Organization Organizing process is effective Principles in Practice (HRO) just sounded too academic when: The following common fire man to have any functional place in our agement practices can make HRO fire community. • You have multiple fire starts; principles relevant to the fire man • You have multiple incident strat agement community: As I began to apply the HRO princi egy objectives; ples and observe its positive effects, • You have lots of resources com After Action Reviews. After action mitted; reviews (AARs) are a great place to • Everyone is tired, and you are exemplify some of the associated Brett Fay is the regional fire use special ist for the Forest Service’s Intermountain trying to keep everyone as safe as HRO principles such as “giving Region. When he first starting applying the possible. strong responses to weak signals.” High Reliability Organization principles When doing AARs you can identify to his work, he was the fire management Are these the times to try some officer for the Dixie National Forest, Cedar these signals that might not other City, UT. thing new? Not usually, of course. wise be evident. Lack of good com
Fire Management Today 28 munication to and from dispatch ciple “A Deference to Expertise.” • The Wildland Fire Situation is an example of a weak signal that As our wildland fire operations Analysis. The Wildland Fire could be important in determining become more complex and Situation Analysis (commonly the health of the overall system. complicated, our ICS system referred to as the "WFSA") • Staff Rides. The wildland fire is designed to respond to these analysis is an example of the management organization uni complexities by deferring to the HRO principle “A Reluctance to versally recognizes staff rides as expertise of a team or incident Simplify.” Creating alternatives outstanding learning tools. Many commander. If you have never and identifying and prioritizing of these learning opportunities been confronted with a certain objectives are examples of making focus on fire fatalities or other situation before, wouldn’t it make a decision more complex. HRO significant organizational fail sense to defer to someone who is principles identify that by making ures. In this way, staff rides can more experienced—even if they decisions more complex helps to be an optimum process to help represent a lower pay scale than identify more of the nuances that define where “failures”—both you? surround a given decision. Once big and small—occurred. The these nuances are identified they “Preoccupation with Failure” are used to make more reliable HRO principle lends itself to the How do you present decisions. practice of staff rides. the HRO principles to a • Incident Command System. group that really doesn’t High Reliability Organizing is The structure of the Incident want another “tool?” another tool that helps us better Command System (ICS) can be manage unexpected events. Is it used as example of the HRO prin the latest best thing? Maybe; maybe not. It's up to each of us to determine.
Try it, you might like it!
Volume 68 • No. 2• Spring 2008 29 ca s e st U d y : th e hi g h reliaBility or g a n i z i n g Fi e l d st U d y o F t h e ok e F e n o k e e na t i o n a l Wi l d l i F e re F U g e Paul Keller
hen we observe the evolution of the fire "W management program of the Okefenokee National Wildlife Refuge system tomorrow, we are going to be observing collaboration in a complex environment,” Dr. Karl Weick, internationally recog nized expert on High Reliability Organizations (HROs) points out to the 120 wildland fire management employees participating in the May 2005 Managing the Unexpected in Prescribed Fire and Wildland Fire Use Operations – the Second Workshop on High Reliability Organizing event in Jacksonville, FL. How can we better manage and be better prepared for unexpected events in the wildland fire arena? Managing the Unexpected—The second workshop on High Reliability “We need to pay attention to the Organizing—is part of a continuing organized effort to help improve this country's mistakes that they don’t make and prescribed fire, wildland fire use, and fire suppression programs. The workshop's special how they have designed themselves focus is a field study of the Okefenokee National Wildlife Refuge system. Photo: Tom Iraci, to avoid making these mistakes,” Forest Service, Pacific Northwest Region, 2005. Weick tells the workshop partici cies and various levels of the wild- “You need to ask yourselves: pants, who represent several agen land fire organization. How are they set up to avoid mak “Make this a learning “Are there parallels between the ing mistakes? moment. When we Okefenokee program and what you do back on your own home units?” get back, we’ll pool Have they identified clues that Weick asks his attentive audience. indicate that they’re moving our experiences. We’ll toward mistakes? reflect The well-known Managing the on what we saw.” Unexpected author and esteemed How are they prepared to recover University of Michigan professor from mistakes? continues to prepare the workshop Paul Keller served as managing editor of attendees—primed all week in High Do they know where their expertise Fire Management Today from June 2005 Reliability Organizing principles— to June 2007. A former hotshot firefighter is located to prevent problems—to and newspaper editor and publisher, he for their impending “hands on” be able to contain these problems works as a technical writer-editor for the field visit case study of the com in the early stages?” Wildland Fire Lessons Learned Center plex Okefenokee National Wildlife and for the Forest Service’s National Fire Refuge system. Systems Research and Fire and Aviation Management programs.
Fire Management Today 30 Ongoing Effort The workshop's overall This all-day “Managing the Sponsored by the Wildland Fire stated theme is to Unexpected” excursion includes: Lessons Learned Center, this work "Help us improve our • An indepth presentation of the shop is part of an ongoing, orga country's wildland nized effort to lessen the chance of Okefenokee National Wildlife future prescribed fire escapes and prescribed fire and Refuge’s fire history and pre to increase the chances of replicat fire use programs scribed fire program; ing our wildland fire management by exploring HRO • A “hands-on” tour of the successes. Okefenokee swamp ecosystem; principles." and
Like all three of the workshops • An introduction to the Georgia initiated by the center, this effort “Keep tabs on what surprises you,” Forestry Commission, Florida is to encourage and advance the Weick underscores prior to the Division of Forestry, and Forest strong tie between “High Reliability Okefenokee field visit. “Look for Service, and their related fire Organizations” and “Learning good examples of High Reliability management roles. Organizations.” Dave Christenson, Organizing principles. Make this the Wildland Fire Lessons Learned a learning moment. When we get The complete DVD of this week- Center’s assistant manager, served back, we’ll pool our experiences. long learning event, that includes as the workshop’s lead planner. We’ll reflect on what we saw.” discussions of High Reliability Organizing principles and how The workshop’s central highlight The 396,000-acre (160,000-ha) ref they can be incorporated back on and learning platform is the field uge was established in 1936 to help home units, is available through visit of the U.S. Fish and Wildlife preserve and maintain the swamp’s the Wildland Fire Lessons Learned Service’s Okefenokee National health and natural features. Fire Center at
Volume 68 • No. 2• Spring 2008 31 ca s e st U d y : hi g h reliaBility or g a n i z i n g a n d pr e s c r i B e d Fi r e o n t h e Bo i s e na t i o n a l Fo r e s t
High Reliability Organizing: Applying It Instinctively
David Olson and Deirdre Dether
igh Reliability Organizing is not rocket science. In The introduction of any smoke from prescribed H fact, we often implement fire into this city can spark a plethora of media parts of it without knowing its interest, community concern, and regulatory terms. Learning more about High Reliability Organizations (HRO), agency oversight. though, will most certainly help you. By understanding the opera tions of an HRO, you can strength tions, we risk losing our prescribed same time, we acknowledged poten en your program implementation fire program. tial smoke impacts and the various and your ability to improve fire steps that we take to minimize the management or other operations. Using High Reliability potential of smoke intrusions. Our Organizing Practices target audience included not only residents but also recreationists and Every year, the Boise National The Boise National Forest staff hunters whose key seasons overlap Forest prescribed fire program began searching for a better way with our spring and fall prescribed burns an average of 7,000 to 8,000 of “doing business” that eventually burn seasons. acres (2,800 to 3,200 ha). The for led to the use of three fundamental est is located near Idaho’s capital, High Reliability Organizing prac We now use an interagency which is the third largest metro tices: politan area in the northwest, and approach that includes our sur rounding Payette and Sawtooth introduction of any smoke into the • Mindful awareness, National Forests, the Bureau city can spark a plethora of media • Anticipation, and of Land Management’s Boise interest, community concern, and • Containment. regulatory agency oversight. District, and the Southwest Idaho Department of Lands. These com After a particularly strong smoke bined agencies use the following In addition, with rural populations event in downtown Boise, the for tools to inform and alert the public rising and an increased emphasis est staff decided to improve public to planned prescribed burns: on wildland-urban interface treat awareness by better explaining our ments, the potential for smoke prescribed fire program. The les • Produce and distribute an annual problems impacting a vociferous son learned from this controversial booklet to elected officials, public is huge. Using smoke man event was that we can’t surprise media, smoke-sensitive citizens, agement standard operations, such people with our smoke. With this and others that describes every as following regulatory agencies’ heightened awareness, we devel planned burn for the entire year, protocols and using minimal public oped and implemented a variety including acreage, legal location, information, is not always enough. of products and methods for more approximate time of ignition, and Potentially, if we do so in all situa- effective public outreach. the burn’s purpose; • Establish a telephone hotline and Our intent was to comprehensively update it weekly or even daily if David Olson is the public affairs officer and explain how we developed our for Deirdre Dether is the forest fuels planner needed; for the Boise National Forest, Boise, ID. est’s prescribed fire program. At the
Fire Management Today 32 • Establish a Web page (
A Roadside Demonstration
A very concerned parent stops and approaches one of the Boise National Forest’s roadside prescribed fire information centers. This father has a young asthmatic daughter whose health is being impacted by the current prescribed burn’s smoke. He is obviously disgruntled.
The man begins to fire questions about why the Forest Service is even doing this burning. He implies that the agency is just a bunch of “pyros” who like fire.
The Boise National Forest employees staffing this prescribed fire roadside information stand take the time to explain the entire prescribed burn to him. They give the man a booklet that emphasizes the forest’s desire to inform all area residents of the prescribed fire program to help ensure that everyone will know where and when a burn is planned.
The Forest Service employees explain to the man that increasing his family's awareness about prescribed fire is the reason for the roadside information centers. They emphasize how they want to know about his daughter’s health situation so that he and his family can always be directly alerted to planned burns.
The man’s upset demeanor was gone. He walks back to his car realizing that the Forest Service truly is con cerned with his family’s sensitive health care issues.
The prime High Reliability Organizing practice associated with this real world example is “containment.” Despite all of the Boise National Forest’s efforts to inform the public about prescribed fire events, a sur prised, uninformed, and disgruntled resident surfaced.
If the roadside information center had not been available for this person to make human contact, a poten tial problem could have escalated into a serious health issue involving air regulators and elected officials— all stemming from one disgruntled citizen.
And, remember, this was all done without fully realizing that this practice had anything to do with High Reliability Organizing.
Volume 68 • No. 2• Spring 2008 33 deck tasks. Each colored shirt sup contacted the following people with The potential for smoke ports the prime mission—launch information about the burn: problems impacting ing and recovering the aircraft. a vociferous public is Without every colored shirt, the • The Senator’s staff, overall job would fail. • The regional EPA director (a huge. speaker at the event), Such is also the case with the • The State DEQ air quality man prescribed fire program. The ager (another speaker), and sitivity to all facets of a burn), and prime task is to conduct the burn. • The Idaho City School superin “containment” (what mitigation However, by producing the booklets tendent. measures might be necessary) dem and developing the other informa onstrates why a prescribed fire pro tional tools, a “different colored This was all done to eliminate sur gram is, indeed, an HRO program shirt” is used, helping the overall prises and facilitate coordination. waiting to happen. program succeed with public sup By being aware of the event, antici port. Once again, anticipation, pating potential problems, and Can we claim success at the Boise awareness, and containment are using products and communication National Forest? During the past successfully engaged. to contain a potential significant several years, the number of smoke issue, success was achieved. complaints we receive has dropped The ultimate ironic story of antici to almost none. Informal surveys pation, awareness, and contain End result: Everyone supported indicate that people know why we ment occurred when an Idaho U.S. continuing the burn and was pre are burning. Senator was invited to be the key pared to acknowledge—and even note speaker at an Environmental defend—this prescribed fire that The challenge now is to not put Protection Agency (EPA) and Idaho could potentially intrude its smoke High Reliability Organizing “in the Department of Environmental into the significant award ceremo bank.” To truly implement an HRO Quality (DEQ) grant award ceremo ny. While this didn’t happen, the requires continuous awareness, ny to tout the new pollution reduc burn’s column was visible from the anticipation, and containment. As tion equipment recently applied to event site. new residents come into the Boise Idaho City school buses. On that area, which boasts one of the fastest very same day, the Forest Service’s What You Can Do growing populations in the Nation, we realize that we need to continue Idaho City Ranger District was con Public emotions, fear, and inter ducting a prescribed fire—within 1 to build a program that will be suc est are all stimulated by fire on cessfully supported by the public. mile of the event site. the landscape. To implement our prescribed fire program, the public We continue to analyze the poten This big ceremony was less than needs to understand and prepare 18 quick hours away when we first tial for errors that we don’t want to for a burn. Thinking the event occur by always searching for the heard about it. To facilitate com through with “awareness” (what munication, gain understanding of weak signals that indicate a prob can go wrong with the public), lem is developing. the prescribed fire operation, and “anticipation” (what are the opera ensure completion of the burn, the tional objectives that require sen- Boise National Forest immediately To learn more about how we’re accomplishing this, visit the Prescribed Fire in Southwest Idaho Web site
Consider exploring the High Reliability Organizing principles and practices to realize the following outcomes: • Achieving integrated involvement during high-tempo times, • Preventing situations that could turn out badly from occurring, and • Containing problems before they become bigger problems.
Fire Management Today 34 sp r e a d i n g t h e Wo r d o n hi g h reliaBility or g a n i z i n g Paul Keller
f you know what Nomex is, but you haven’t heard about High There was no question that High Reliability I Reliability Organizing—wildland Organizing deserves to be included in the wildland firefighters, we have a problem. fire management toolbox. Before this issue of Fire Management Today, had you Fire Lessons Learned Center), a even heard about High Reliability core interagency group convened in It was evident that the High Organizing? Better yet, has this 2006 to determine how the tenants Reliability Organizing principles, essential safety “tool” yet made it of High Reliability Organizing—the that help people to think more into your or your unit’s wildland vital organizational learning con clearly about how to perform their fire management toolbox? duit of these workshops—could be work, could help ensure safer and shared with even greater numbers more effective day-to-day outcomes. If your answers are “no,” you’ll be of wildland fire practitioners. Thus, it became obvious that High happy to know that there’s a con Reliability Organizing deserved to certed effort currently underfoot to These prior productive workshop be included in the national wildland ensure that you, along with every sessions were based on the High fire management toolbox. What’s one else in the wildland fire com Reliability Organizing principles more, the Wildland Fire Lessons munity, have the opportunity to get developed by Dr. Karl Weick and Learned Center organizers realized up close and personal with High Dr. Kathleen Sutcliffe in their that, ideally, every unit should be Reliability Organizing. book Managing the Unexpected: benefiting from this valuable tool. Assuring High Performance in an That’s a good thing. Age of Complexity. In the after Advanced Seminar math of all three of the annual Next step: In January 2007, In fact, the popular opinion on weeklong workshops, the followup under the organizing savvy implementing this innovative pro critiques, evaluations, and after- of the Wildland Fire Lessons cess—shared by everyone from the action reviews from both partici Learned Center, 27 key inter- Forest Service’s national director of pants and staff confirmed that these agency people from around the Fire and Aviation Management to learning events were highly benefi country—all familiar with High the on-the-ground firefighter—is: cial to the wildland fire workforce. the sooner, the better. “This is not another checklist. It’s not just another list that you Here’s a quick up-to-date summary. pull out of your Incident Response Pocket Guide. High Reliability In the wake of the third Managing Organizing is a way of doing business. It’s how you think about a the Unexpected in Wildland Fire problem and how you prepare for that problem. Workshop (hosted by the Wildland Whether it’s suppression, wildland fire use, or prescribed fire—it’s an ever-changing environment that we constantly have to adapt to. Paul Keller served as managing editor of That’s why any technique that helps us to learn and to adapt to these Fire Management Today from June 2005 situations is one I’m going to latch on to it and use it, you bet.” to June 2007. A former hotshot firefighter, newspaper editor and publisher, he now works as a technical writer-editor for the –Brett Fay (former Fire Management Officer) Wildland Fire Lessons Learned Center Regional Fire Use Specialist and the Forest Service’s National Fire Systems Research and Fire and Aviation Intermountain Region Management programs.
Volume 68 • No. 2• Spring 2008 35 Reliability Organizations (HROs)— participated in an Advanced High Reliability Organizing Seminar. The participants included fire manage ment officers, assistant fire man agement officers, fuels planners, training specialists, researchers, and safety officers.
Discussions at this seminar again indicated that extra heads-up employees are already spreading the High Reliability Organizing “mind set” through the wildland fire ranks via a unit-level grassroots effort. A method for teaching the High Reliability Organizing principle “Sensitivity to Operations” is demonstrated through a special sand table exercise at the Facilitating “In my past, we have tried to intro High Reliability Organizing in Wildland Fire workshop. Photo: Dominic Kovacevic, Fire duce High Reliability Organizing Imagination Center 2007. to people that I’ve worked with both on a rappel crew and for the that they’re uncertain about or feel 4 years that I was the lead, annual Core Teaching Group uncomfortable with. We all have a fire refresher instructor for our “Our motive is to expand the pool responsibility to look out for one forest,” explained seminar par of people who can go out and another’s safety.” ticipant Tim Lynch, project leader teach High Reliability Organizing for the Missoula Technology and in the real world—out in the Held in Tempe, AZ, Weick and Development Center’s helicopter field,” facilitator Mike DeGrosky Sutcliffe—the HRO dynamic duo— rappel equipment and procedures explained the opening morning of facilitated this advanced seminar, program. the Facilitating High Reliability sharing their wisdom and insights Organizing in Wildland Fire with this core wildland fire con “We were fortunate to have a pro Workshop, held in Nebraska City, tingent. This productive session gressive fire staff,” said Lynch, a NE. Cosponsored by the Wildland helped pave the way for the next former rappeller and smokejumper. Fire Lessons Learned Center and step in the broader HRO “teaching” “I was given the latitude to teach The Nature Conservancy, this work process, the first Facilitating High basic High Reliability Organizing shop’s future core teaching group Reliability Organizing in Wildland principles at all of our forest-wide audience was immersed in how to Fire Workshop. fire refresher courses. In teaching effectively teach and facilitate the the refresher, I always described the five key High Reliability Organizing Three months after the Advanced High Reliability Organizing pro principles. High Reliability Organizing cesses that we used to create and Seminar, this resultant facilitat teach mindfulness and ‘sensitivity A cadre of master instructors who ing High Reliability Organizing to operations’ (one of the five High had attended the previous Advanced Workshop convened a select group Reliability Organizing principles) High Reliability Organizing of highly motivated interagency on our rappel crew.” Seminar conducted the event. wildland fire practitioners. Lynch continued, “One of things Many of the cadre members were that we stressed very hard was also involved in the first three that no matter what your position might be on the crew, you might The HRO principles, which help people to think be the one who notices something more clearly about how to perform their work, important. We let everyone know that it’s important that they feel could help ensure safer and more effective comfortable bringing things up day-to-day outcomes.
Fire Management Today 36 national Managing the Unexpected The most powerful action we can take is Workshops. implementing High Reliability Organizing and, “We are all here this week because especially, to model it. we want to learn and we want to teach others,” Paula Nasiatka, the • Explore examples of integrating • Incorporating them into their fire Wildland Fire Lessons Learned HRO principles into organiza curriculum and training, Center manager told workshop tions, • Creating an HRO-based burn plan attendees. “You will be making a • Help people understand the histo writing workshops, difference as leaders as you famil ry and genesis of High Reliability • Building High Reliability iarize yourselves more and more Organizing, and Organizing into large fire assess with how we can best facilitate • Prepare people to teach others ments, mindfulness and the HRO guiding about the fundamentals of High • Being available for additional principles.” Reliability Organizing. High Reliability Organizing audits, training, and mentoring, Teaching Guide In the meantime, people will also • Revising the prescribed fire plan A teaching guide Introducing be sharing the word about High formats using High Reliability High Reliability Organizing to the Reliability Organizing with their Organizing, and Wildland Fire Community—From fellow wildland fire associates on • Incorporating High Reliability the Field to Line Officers has been their own—just as they’ve been Organizing into their annual fire published to help spread the High doing for years. refresher courses. Reliability Organizing word. For Even as you read this article, wild- the most part, this guide reflects “Right now, all we can affect is our land fire people are most likely presentations and feedback from sphere of influence—the wildland out there spreading and model the 3-day workshop. fire community,” said Facilitating ing High Reliability Organizing. High Reliability Organizing In addition, Nasiatka informs By using and following this guide, Workshop participant Dave Allen, that another Facilitating High the teacher—who knows, it could fire management officer at Sequoia Reliability Organizing in Wildland be you—will understand the National Park. “The most powerful Fire Workshop is being planned for fundamentals of High Reliability action we can take is to implement 2008. Organizing and will be better pre High Reliability Organizing and, pared to facilitate these principles especially, to model it. It’s hard to So if you’re wearing Nomex and to others. This guide is specifically go out and try to ‘evangelicalize.’ you haven’t yet heard about High designed to: If a line officer doesn’t push this Reliability Organizing—this pro forward, you can’t let that stop you cess designed to help people better • Prepare people to spread HRO from implementing and modeling manage unexpected events—you principles throughout the wild- it.” soon will be. land fire community, • Reinforce HRO principles with Allen’s fellow workshop participants That’s a good thing. examples from both within and also pledged to spread the HRO outside the wildland fire arena, principles and concepts by:
Volume 68 • No. 2• Spring 2008 37 te a c h i n g Mi n d F U l n e s s t o Wi l d l a n d Fi r e F i g h t e r s Dave Thomas
or the last 3 years I have want to adopt the mental posture of Under current conditions, we must taught half-day workshops, mindfulness. attempt to apply new methods to F conducted 1-hour lectures, mindfully think about the decisions and provided general aware I explain how the room for deci and forecasts that are a usual part ness speeches about the Weick/ sion error in fire operations has of our wildland fire jobs. Droughts, Sutcliffe model of High Reliability decreased during the past five declining natural water supplies, Organizing as described in their decades. In my days as a young fire longer fire seasons, hotter days and book Managing the Unexpected: fighter from the late 1970s to the warmer nights, high fuel levels, Assuring High Performance in an late 1980s, you could make a few have all caused our fire operations’ Age of Complexity. tactical mistakes and probably not decision frames to narrow. Today— suffer severe on-the-ground conse just as the fire environment has This article is a series of musings, quences. changed—it is imperative for us to conjectures, and recommenda change and become more acute at tions pulled from this teaching sensing the harsh realities of this experience. My intent is to pass The room for decision/ radically altered fire environment. on some of the lessons that I have error in wildland learned teaching High Reliability fire operations has Understanding Organizing, and to pose recommen Mindfulness dations for further study. decreased during the past five decades. As a High Reliability Organizing instructor, it is important to dif The most important facet of any ferentiate between Western notions talk on High Reliability Organizing Today, however, mainly due to the of “mindfulness” and Eastern inter is immediately establishing the heating of the Earth through global pretations (such as Buddhism). rationale for why busy wildland warming and a build up of fuels— To some, the word mindfulness fire managers, who are already firefighters are working within is value laden, having religious overloaded with firefighting safety an environmental framework of connotations. For me, it is cru issues and decisionmaking respon weather and fuel never experienced cial to explain that mindfulness sibilities, should take the time to before. Errors that we might have is a particular way of being in the study the new High Reliability “got away with” in the past could world as described by Harvard Organizing concept of mindfulness. more easily become catastrophic researcher Helen Langer in her today. book Mindfulness (Langer, E.J I begin by describing a number of 1989. Addison-Wesley Publishing reasons why busy people might I support this observation with Company, Reading, MA). Langer data from Dr. Tom Swetnam at the described a particular way of being Tree Ring Laboratory in Tucson, alert to novel distinctions. Weick Dave Thomas, 2 years retired as the AZ (
Fire Management Today 38 mindful of our fire operations a We must be more serious accident can still occur on acute at sensing the Wildland firefighters must strive a wildland fire in which many fire dangers of the wildland to do everything in their power to fighters are burned to death. instill freshness and new life into fire environment. our old, standby notions of safety to I don’t write this to be a pessimist ensure that safety doesn’t degrade. or to undermine the confidence Aaron Wildavsky’s book Searching of the brave men and women who for Safety (Transaction Publishers Easy To Be Mindless work in wildland fire operations. 1988). Wildavsky implies that Using case studies, I explain how In fact, I am reluctant to even call safety is not a bankable item that easy it is to go “mindless,” regard attention to these perceptions. I do draws interest in some safety bank less of how good an individual or so simply as my own preoccupa account. In fact, he says the exact organization is or how much expe tion with failure (one of the five opposite is true—safety, with time, rience an organization has with High Reliability Organizing prin actually degrades: “Safety degrades; fire. If we are not constantly wary ciples). Under our current, ongoing it too has a half-life. Why can’t we of losing our situational awareness, droughty conditions and high fuel take for granted whatever level disaster is inevitable. levels, a fire-related tragedy can of safety that has been attained? easily occur. Because unless safety is con To support this argument, I tinuously reaccomplished, it will describe a horrible few minutes of As I continue with my introduc decline....” mindlessness that occurred on a tion, I often use an idea taken from prescribed burn in Ontario, Canada,
Deep Smarts
For the past year, I, along with I am just beginning detailed analy have adverse consequences in Dr. Dorothy Leonard of the ses of these deep smart interviews. almost any of this high risk Harvard Business School, have One thing I have already noticed is stuff…so something eventually been video-interviewing fire man that these people with high exper will go wrong.” agers who are recognized by their tise in various fire management peers as being highly-skilled at responsibilities, in many cases, I have used Daniels’ quote in their jobs. were naturally practicing the con many HRO talks as an example of cepts of mindfulness. someone who was always preoc These people, to use Dr. Leonard’s cupied with failure, a key HRO phrase, possess “deep smarts,” This is an important lesson for fire principle. Richard Rothermel, the ability to perceive the work managers just entering their fields the Missoula Fire Laboratory world in novel ways and to con of work, that the men and women scientist who developed the struct speedy, workable solutions who came before them—the pio Rothermel fire spread equation, to a majority of problems they neers in prescribed fire, wilderness told us that he wished the spread encounter—problems that they fire management, fire behavior rates and fire intensities that his often have not previously encoun prediction—were already practicing model produced could have been tered and, thus, they must quick HRO principles. banded in a web of probabilities. ly develop unique solutions. I have reconstructed Rothermel’s For instance, Orville Daniels, for sentiment to mean that he was People with such deep smarts can mer supervisor of the Lolo National reluctant to simplify, and— get a lot of work accomplished Forest in Montana, a recognized another key HRO principle—he without serious disruptions. They pioneer in wildland fire use man believes even the quantitative help the company earn profits, agement, told us in his interview outputs from his fire spread be more competitive, and get the that when managing a fire that is model should be looked at with a work done with fewer accidents. being allowed to burn “you will wary eye.
Volume 68 • No. 2• Spring 2008 39 Mindfulness will help us bailiwick be chess, poker, skiing, Just as firefighters commonly use get more fire back into mountain climbing, foreign lan the phrase “slide tray” to describe these fire-dependent guages, or cooking. the variety of fire experiences that they have seen or experienced and ecosystems. To support this view, I tell stories that they now hold within their about famous sports figures (Tiger heads as analogues to be used on in which a highly professional Woods—truly a master of mindful similar fires in the future, mindful burning crew in just 7 minutes was ness), as well as people in the arts, firefighters need metaphors that burned over. Seven young foresters to illustrate how excellent practitio encompasses the style of thinking died in that fire. If it can happen to ners are continually polishing their that they are doing. this highly motivated and experi skill sets. To masters in sports and enced prescribed burning crew, it the arts, just being good is never Academics working within the field can happen to any burning crew. good enough. of high reliability should describe the differences between their Next, I explain the irrationality Finally, I make the claim that to approaches. What is the primary (mindlessness) of always learning sense problems in the fire envi difference between Karlene Robert’s our primary safety lessons through ronment while they are small and approach to High Reliability trial and error. It is our job to be weak—before they’ve incubated Organizing and the approach estab better at anticipating errors before into larger, more devastating prob lished by Weick and Sutcliffe? To they occur, before a brutal audit lems—increases the number of wildland fire practitioners it is tre forces us to notice the discrepant opportunities that we will have to mendously difficult to separate the events in the fire environment. safely put fire back into fire-depen subtle differences in theory and to The following quotation, which dent ecosystems. establish whether these differences, reinforces this view, is taken from in the end, really matter. French disaster expert Pat Lagadec: After all, the wildland fire commu nity works hard at becoming better Also, I have found it particularly “The ability to deal with a crisis at enhancing the ecosystems that valuable to have at least a taste of situation is largely dependent on they are assigned to protect and Weick’s earlier books on sensemak structures that have been developed preserve. Accident prevention helps ing. These prior works provide before chaos arrives. The event accomplish this primary mission. the groundwork for his particular can . . . be considered an abrupt version of what it means to “make brutal audit: at a moment’s notice, The fewer mistakes we make: sense” of the world. I recommend everything that was left unprepared the essays in his Making Sense becomes a complex problem, and • The fewer fire use events will get of the Organization (Blackwell every weakness comes rushing to out of control, Publishing Limited 2000). the forefront.” • The more chances we will have to practice our skills as natural Preparing mindful case studies I then make the case that to be resource managers and stewards is much different than preparing good at mindfulness, to learn the of the land, and rational cause-effect case studies. cognitive skills necessary to regu • The more fire we will get back I have found it difficult to prepare larly practice mindfulness, is to into these fire-dependent ecosys case studies from past wildland fire begin the movement from being tems. accidents or escaped prescribed a novice firefighter to one who is burn reports that sharply delineate acquiring the skills of a master. It is Recommendations the principles of mindfulness. It a lifelong journey. is relatively easy to provide simple Firefighters need to develop meta analyses to the potential etiology phors for mindfulness as it is per Polishing Skill Sets of complex firefighting errors. It tains to wildland fire operations. is harder to add nuance and novel Such a transitioning firefighter These metaphors should be words thinking to the same incident in wants to move to a higher level of or phrases that envelope the whole hindsight. Once a wildland fire personal accomplishment in his or process of thinking toward novel investigation report is published her profession—just as all profes distinctions about routine and, through hindsight, the cause sionals aspire to do, whether their fire operations.
Fire Management Today 40 It is imperative for us to change and become Simplification of the wildland fire more acute at sensing the harsh realities of this environment, and the thinking processes used by firefighters work radically altered fire environment. ing in that environment, results in thinking that the environment is simple and somehow, control of an event becomes known, it Beware of Simplifying lable. Although such thinking is becomes difficult, if not impossible, We have attempted to make operat somewhat comforting, which in to take away the sense of inevitability. ing in a complex world simple and and of itself could be dangerous, straightforward. But mindfulness the intrinsic complexity of the fire A tip sheet or checklist prepared by requires us to think with more environment is lost in this tactical both academics and on-the-ground serendipity, with more variety and narrowing of focus. practitioners would provide an complexity. To paraphrase Weick outline of how one might prepare and Sutcliffe, it takes complexity In the classroom, we must fight to mindful case studies. to understand complexity and we maintain the feisty, ever question must be cautious every time we ing, creative beauty of mindful The culture of wildland firefighting attempt to simplify the world. thinking. for the past three or four decades We must fight the tendency to has been one of simplifying fire turn High Reliability Organizing Hopefully, in some small way, these operations into standard operating training programs into classes that remarks will help other teachers of procedures, into checklists (the become nothing more than exer mindfulness to be better prepared 10 standard firefighting orders), cises in tactics—if the hotshot crew for their classroom adventures in and the simplifying of simplifica would have done this, that burn- teaching this new style of sensing tions (Lookouts, Communications, over would not have happened...if the dangers that most definitely Escape Routes, and Safety Zones). the burn boss would have written lurk in the world of wildland fire a better burn plan, the burn would operations. not have jumped the control lines.
Volume 68 • No. 2• Spring 2008 41 a pe r s o n a l ac c o U n t o F re s i l i e n c e a n d pr e s c r i B e d Fi r e Riva Duncan
any who work in fire man agement will, at some time M in their career, face some thing difficult, an “abrupt and bru tal audit” (Lagadec 1993) that will shake their confidence at best and leave them heartbroken at worst.
I know.
How do some of us get through those dark days, learn from our mistakes, and continue to do our jobs as best we can? What makes some of us “bounce back” from a serious accident, a fatality, or an escaped prescribed fire and contin ue to do the work on the land that is not only important but neces The first spot fire on the Cascade II Prescribed Burn. Photo by Matt Preece, Uinta sary? Why are some people able to National Forest. adjust and adapt quickly in a rap- about fire behavior and fire ecology. and a growing season burn. And idly changing fire environment? Most of the people I worked with they took the time to teach me a were from the South. Many grew true appreciation of such “hands- Rather than speculate about what up there. Not only had they been on” fire ecology. They taught me to other people possess that helps burning with the Forest Service drop a match or carry a drip torch them “get back up on that horse,” I for years, several of them had been mindfully, and to always know the will tell you my story. burning with their daddies and outcome and consequences of my granddaddies since they were kids. actions. It was a wonderful gift. In 1998 I began, what would prove to be, a wonderful 5–year ten- When I arrived from my north- Safe Learning ure working on the Apalachicola east “asbestos” forest, folks will- Environment National Forest in northern ingly transferred their land ethic Florida. The Apalachicola has the We had a very supportive district to me. The fire practitioner ranger, Andy Colaninno, who largest prescribed fire program of “heroes” whom I had the privilege any other national forest in the encouraged a safe, learning atmo of working—and learning—with sphere. He wanted his employees country. In addition, wildland fires helped me to understand why fire can ignite here during any month to be creative and innovative and to is “good.” They knew the difference learn from their errors. of the year. between a dormant season burn With a program of burning approxi- mately 100,000 acres (40,000 ha) They taught me to drop a match or carry a drip per year, this is the place to learn torch mindfully and to always know the outcome and consequences of my actions. It was a Riva Duncan is the deputy forest fire man- agement officer for the Klamath National wonderful gift. Forest, Yreka, CA.
Fire Management Today 42 High Reliability Organizing Principle #4: Because of our burn, community relations with the Forest Service A Commitment to Resilience became strained, to say the least. The media was harsh. Our for- est’s public affairs officer was One such lesson occurred when My Brutal Audit Occurs admonished—off duty—in the post I was a burn-boss trainee on a After almost 6 years of prescribed office. Some of our firefighters were 2,000-acre (800-ha) unit. Our two burning and fighting fire in Florida refused service at a local gas sta principle lighters—both fairly new under my belt—and possessing tion. Members of the public wanted to the Apalachicola—were driving a solid love of fire, as well as the some of us fired. all—terrain vehicles (ATV) with ecosystems that thrive on it—I rear-mounted drip torches. Driving accepted a job in Utah as the forest Internally, it wasn’t much better. around the burn unit’s perimeter fuels specialist on the Uinta and Some of our nonfire coworkers after we had completed our ignition Wasatch-Cache National Forests. It were just as angry at us as was the operations, I came across a group could not have been more different public. And the finger-pointing and of local hunters who informed us than Florida. Not just the topog blame deflecting even began to flare of a spot fire across the swamp— raphy, weather, and fuel types, but up between my work associates. outside the unit. these two forests were in the early stages of building prescribed fire I woke up many nights trying to The burn boss trainer called the programs. understand what went wrong on helicopter manager to prepare for a that burn—and what I could have reconnaissance flight. Sure enough, I was only 4 months into my new done differently. I wondered about we had fire outside the unit. We job when the audit occurred. The the decisions I made and how the looked for a good place to burn out Cascade II Prescribed Fire on the outcome might have been different from and then talked in the ground Uinta National Forest was intended had I done something else. forces. My fire management officer to reduce hazardous fuels and told me that I’d better call Andy, regenerate aspen on 600 acres Those of us in overhead and plan the district ranger, at home (it was (240 ha). I was the type 1 ignition ning positions and some of the line Saturday). On the phone, Andy specialist. By 5 p.m. the day of the officers endured a national-level asked if we were catching the slop- burn, it was declared an escape. investigation. When the report was over. I informed him that we were, released, many of us were unhappy that we were burning out a section The fire would eventually burn because we felt it did not portray of the adjacent unit and it should 8,000 acres (3,200 ha)—mostly the events or the causal factors be finished soon. He said “sounds private lands. The smoke from accurately. But I’m sure everyone good” and told me that I could fill our escape was so bad in Salt Lake who has gone through one of those him in on Monday. City that the street lights came investigations feels the same. on during the day. Salt Lake City After we finished the burn, we International Airport nearly closed Several weeks later, some of us stood around the trucks to talk down. For several days school were notified that an administrative about it (we didn’t call this an recesses were cancelled, football investigation was coming. I gave “after-action review” back then). We practices were moved indoors, and my testimony the Monday following soon discovered that the two ignit a few people even put their asth Thanksgiving at a downtown Provo, ers on ATVs had crossed the swamp matic children on planes to visit UT, hotel. It wasn’t until well after without realizing it and had lit the relatives elsewhere. other side. After some good-natured ribbing, we recognized that putting two people who weren’t familiar The smoke from our escape was so bad in Salt with the unit together as our prin ciple lighters was a bad idea. We Lake City that the street lights came on during the never did that again. day. Salt Lake City International Airport nearly closed down.
Volume 68 • No. 2• Spring 2008 43 We displayed an And when the two professors, At a recent meeting with Sutcliffe unspoken spirit of Dr. Karl Weick and Dr. Kathleen and Weick, Dr. Sutcliffe said that teamwork and Sutcliffe, talked about mindful bouncing back from hardship or ness and managing the unexpected tragedy was not a “big deal, people common goals. (Weick and Sutcliffe 2001), some do it all the time.” She emphasized thing clicked in my brain. If I that people who did so appeared to Christmas that disciplinary actions had known about these principles have one thing in common—they were handed out. before our Cascade II prescribed had dealt with hardships or adver burn, would the outcome have been sity before, but on a smaller scale. High Reliability different? Concepts I immediately thought of my safe I did know that these new high reli learning environment and experi So, what did I do? In the aftermath ability concepts would help me to ence in Florida, where I was once of this prescribed fire escape, no do my job better in the future. indirectly responsible for having one would have blamed me—or any a prescribed fire escape—and no of us involved with this incident— Exhibiting Resilience blame was ever assigned. if we had just thrown our matches away, put down our drip torches, On October 15 and 16, 2004—just When I reflect back on the Halls and gone on with other things like 1 year after the Cascade II escape— Fork burn, I think resilience was fire suppression. But I couldn’t do we successfully implemented applied in its planning. And, we all that. My land ethic wouldn’t allow the 3,000-acre (1,200-ha) Halls had a desire to get back to work it. Fork prescribed fire on the Uinta National Forest. Most of us on this after our experiences that followed the Cascade II escape. We bounced Intentionally putting fire on the burn had also been on the Cascade back. landscape was and is a part of who I II burn and escape. am. So, I started writing more burn As for my personal resilience, I plans. I began to plan other burns Once again, I served as the type 1 know it was due to the land ethic with some of the forest’s fire man ignition specialist. During this pre that I developed in Florida and the agement officers. Yes, a handful of scribed fire, we looked for weak sig safe learning environment that I us got up, dusted ourselves off, and nals and when things didn’t go as experienced there. I applied the got back to work. planned, we caught them early. We adapted. We displayed an unspoken hard lessons that I learned from Cascade II to this foundation and Our core group believed in the spirit of teamwork and common tried to do even better. prescribed fire program. We didn’t goals. Of course, like most burns, it want to watch it die. And, frankly, wasn’t perfect. This burn, too, had It is a personal quest that is ongo we had something to prove—to its learning moments. But it was a ing. ourselves, to our local communi huge step in the right direction. ties, to the regional office, and to References our coworkers: We knew how to Later, I relayed my story to Dr. Weick and Dr. Sutcliffe. They said Lagadec, P. 1993. Preventing chaos in a burn. crisis: Strategies for prevention, control, it was an example of resilience— and damage limitation. McGraw-Hill The following May, I was in a hotel one of the five principles of a High Publishing.
Fire Management Today 44 as s e s s i n g hi g h reliaBility pr a c t i c e s in t h e Wi l d l a n d Fi r e co M M U n i t y Anne Black, Kathleen Sutcliffe, Michelle Barton, Deirdre Dether
he Office of Inspector General’s to meet organizational challenges 2006 audit of Forest Service posed by complex fire situations. T fire management operations added yet another voice to the Fire managers since have sought growing chorus calling on the continual improvement of fire Federal wildland fire community to knowledge, tools, and equipment. get more fire on the ground (OIG The Incident Command System, 2006). for example, was developed to meet organizational challenges posed by The 1995 National Fire Plan and complex fire situations. Attention Figure 1. The Principles of High Reliability the 2001 Implementation Plan has also focused on human fac Organizing. identify the critical role of wildland tors—the way units are structured fire use in reducing hazardous and how people interact—as well Organization (HRO) is one that fuels conditions, reducing risk to (e.g., Putnam 1996, IAWF 2005). consistently produces the results property and natural resources, and in a dynamic, often unpredictable reducing costs. Yet, meeting these Many key concepts under-girding environment in which the conse goals poses significant organiza organizational effectiveness are quences of errors are catastrophic. tional challenges, particularly when captured in the theory of high reli Accordingly, the error rate of an it comes to fire management’s ability (Weick and Roberts 1993, HRO is substantially lower than capacity to safely manage fire on Weick and Sutcliffe 2001, DeGrosky other businesses in the same field. the landscape. and other articles in this issue). Traditionally, there have been two Simplistically, a High Reliability main approaches to reliability. One The search for improving effective ness of wildland fire management is not new. In 1914, California The most successful organizations Regional Forester Coert duBois spend more time than their launched the Forest Service’s first systematic approach to fire man counterparts considering the agement with then state-of-the-art following factors: management science. The Incident Command System was developed • Preoccupation with failure—detecting weak signals and examining failures or unexpected events in order to understand the health of Anne Black is an interdisciplinary ecologist their system. for the Aldo Leopold Wilderness Research • Reluctance to simplify—resisting the urge to simplify assumptions Institute, Forest Service, Rocky Mountain Research Station in Missoula, MT; Michelle about the world. Barton is a PhD student at the University • Sensitivity to operations—having the “big picture” or the “bubble” of Michigan, Ross School of Business, of what’s going on. Ann Arbor, MI; Kathleen Sutcliffe is an associate dean for Faculty Development • Commitment to resilience—developing the ability to bounce back and Research and a professor of Business and improvise after weak signals are caught. Administration and Management and • Deference to expertise—locating local expertise and creating a set Organizations, University of Michigan, Ross School of Business, Ann Arbor, MI; of flexible decision structures and operating dynamics that take and Deirdre Dether is a fuels planner, Boise advantage of those experts (fig 1). National Forest, Boise, ID.
Volume 68 • No. 2• Spring 2008 45 Consolidating and Consolidating and improving reli individual determine what “well” ability requires understanding meant. While this information was improving reliability where we are today—our strengths primarily used to refine our quan requires understanding and weaknesses. The University of titative survey, comparing these where we are today— Michigan’s Ross School of Business, descriptions with the five principles our strengths and our the Interagency Aldo Leopold of HRO also allows us to build an weaknesses. Wilderness Research Institute, initial understanding of how mem and the interagency Wildland Fire bers of the fire community think Lessons Learned Center have col about reliability. seeks to anticipate events that must laborated in a three-phase study to not happen, identify all possible assess reliability in the fire com We found examples reflecting each precursor events or conditions, and munity. We hope to discover how of the principles, but not every then create a set of procedures nec the wildland fire community thinks aspect of each principle. Table essary to guard against the unde and talks about managing in an 1 provides illustrative quotes of sired outcome. Anticipation focuses unpredictable environment, assess how the fire community embod on picking up weak signals before the breadth and depth of HRO ies aspects of high reliability. In they can incubate into larger, more awareness and behaviors, and better the second phase, we hope this catastrophic events. understand how new ideas diffuse snapshot will resolve into a clearer through the wildland fire commu picture. The second approach to high reli nity. This effort will assist in creat ability considers anticipation. In ing an internal benchmark, identify Some High Reliability Organizing this view, reliability is finding ways examples of exemplary behavior, behaviors are so mundane that to cope with and contain undesired and feed important information people might overlook their value. events as they occur—and before into our training programs. Managing emergencies or accidents their effects escalate. as “incidents within incidents” Building the HRO Image seems an intuitive way to organize Over the past decade, research and exemplifies a commitment to ers have realized that the most The first phase, conducted in the resiliency. Doing so ensures that successful organizations use both late fall of 2006, sought to build the majority of the organization’s strategies. an image of what High Reliability energy remains focused on its pri Organizing practices look like in mary objective (such as support Many units of wildland fire man the fire community (this article ing a wildland fire incident), while agement seem to fit the definition presents some of these findings). making sure that the emergency is of high reliability. Recent doctrine The second phase (Fall 2007) asked adequately addressed as well. discussions, safety dialogues, peer how common were these behaviors reviews of incidents, the creation of across fire organizations? The final On the other hand, simply acknowl the Wildland Fire Lessons Learned phase seeks to identify key mecha edging the build-up of unexpected Center, and the sponsorship of nisms of diffusion and adoption of events—late supplies, late people, the Managing the Unexpected High Reliability Organizing ideas. higher than expected winds, etc.— Workshop series (Keller 2004) are is insufficient to ensure reliability, clearly in support of the Forest To build our baseline understand and it is how individuals and the Service’s efforts to improve safety ing, we interviewed 19 qualified organization choose to use this and effectiveness. individuals from three broad information that influences the levels of the fire organization outcome. Ideally, these activities result not (crewmembers, middle managers, only in greater capacity to safely and decisionmakers) within the We heard several examples of the meet suppression needs but also Forest Service, Bureau of Land situation: meets the growing demand to man Management, and National Park age desirable fires–prescribed and Service. “It’s already 10 o’clock in the morn Wildland Fire Use fires. ing, there are no supplies out there, We asked each to describe an and all the people haven’t arrived.” Can We Build Upon event that went well and another In some of these cases, recognition This Base? that didn’t go well—letting each
Fire Management Today 46 Table 1—Comparison of fire intervals for each forest community based on dominant understory.
HRO Principles and primary Example quotes aspects¹
Preoccupation with Failure “Hey, you know, you really want to be careful • Articulating mistakes that we don’t want to in here ‘cause the winds are really funneling make through. This is a point of concern. You don’t • Treating lapses as signals want people in there at this point…and during • Encouraging error reporting this time of day." • Learning from near misses and errors • Being wary of complacency
Reluctance to Simplify “I wanted to get input from the other people • Acquiring diverse perspectives too, to see if there were any different views … • Taking deliberate steps to question assump because you have a wealth of experience there, tions so I like to use it all.” • Being skeptical of received wisdom • Reconciling differences while maintaining nuances
Sensitivity to Operations “It’s already 10 o’clock in the morning, no sup • Puzzling through publicly plies out there, all the people weren’t even out • Paying attention to the front-line there, winds were slated to come up in the after • Having situational awareness noon.” • Noticing accumulating deviations, update • Being sensitive to relationships Continual status checking throughout the day. “Where you at? How’s it going? I guess...more than anything getting the feed back back from the crews. Is this going to hap pen? Is this is not going to happen? What kind of problems are you encountering?”
Commitment to Resilience “We wanted to witness how our resources • Knowing errors don’t disable worked together…so we… had …a run … to • Detecting, containing, and bouncing back see how everybody worked. That was really criti from the inevitable cal…to put everybody in play in a reasonably • Improvising with fantasy/simulations complex burn but not one that had values at • Gaining a deep knowledge of system risk such that if the burn were to get out of con trol, there would be critical losses.”
Deference to Expertise “You rely on those folks with that local knowl • Having flexible decision authorities edge wherever you go.”
¹The first column is adapted from Weick and Sutcliffe. 2007. Managing the Unexpected: resilient performance in an age of uncertainty. 2nd Ed. John Wiley and Sons, Inc.
Volume 68 • No. 2• Spring 2008 47 triggered contingency plans and to complete total utter failure [as Some High Reliability the task either moved ahead suc a prescribed burn], to suddenly it’s Organizing behaviors are cessfully or was postponed. In oth like “oh, it’s no big deal anymore so mundane that people ers, recognition seemed to increase [once the conversion occurred].” the desire to proceed with the task might overlook their —in the case reported, resulting in We also heard multiple accounts of value. less than desirable outcomes. how an organization lost the ben efit of observation because a person Valuing Good did not feel able or comfortable References speaking up: Argyris, C. 1990. Overcoming organiza Communications tional defenses: facilitating organizational learning. Prentice Hall. 169 p. The organizational science litera “It was a classic case of falling into ture contains numerous references a bad decision trap because nobody Detert, J.; Edmondson, A. 2006. Everyday to the value of leadership, trust, was willing to speak up…I didn’t failures in organizational learning: honesty, and respect among mem Explaining the high threshold for speak feel comfortable about it, but…I ing up at work. University Park, PA: Penn bers; and speaking up, and commu had the least experience of any of State University. 1-60. nication in achieving high perfor the permanent staff in those fuels, International Association of Wildland Fire. mance and reliability (e.g., Argyris in that area, in that topography. So 1990; Detert and Edmondson 2006; 2005. 8th Wildland fire safety summit. I was like it doesn’t look great, but 26-28 April. Missoula, MT: Proceedings Vogus 2005; Weick and Sutcliffe what do I know? I’m really pretty on-line at:
Those interviewed also established The interviewees often described Keller, P. (tech ed). 2004. Managing the communication as an invariable a balance between confidence and unexpected in prescribed fire and fire use component to success and failure— operations: a workshop on the high reli humility—having the confidence ability organization. 10-13 May, Santa Fe, what went well, and what didn’t go to make a move in a risky environ NM. Fort Collins, CO: RMRS-GTR-137. well—prompting inclusion of these ment, yet maintaining a humility issues in our quantitive survey National Wildfire Coordinating Group. that allows them to listen to quiet 1995. 1995 Federal wildland fire manage phase. voices of dissent or dissonance. ment policy and program review. Boise, ID: National Interagency Fire Center. Communications was one of the Those interviewed provide the foun most often cited indicators that National Wildfire Coordinating Group. dational information for further 2001. Review and update of the 1995 a situation is not going well, quantifying and validating high Federal wildland fire management policy. “[If] there's no communication; reliability behaviors in the wildland Boise, ID: National Interagency Fire people are all over the place. You Center. Available online:
Fire Management Today 48 pr o c e e d i n g s o F t h e Wi l d l a n d Fi r e sa F e t y sU M M i t s Martin E. Alexander and Bret W. Butler*
he International Association of held in 2006 has maintained that Wildland Fire (IAWF) is a non concept established in 2005. With T profit, professional association each successive safety summit, representing members of the global the previous proceedings will be wildland fire community. The pur included with the current one, pose of the association is to facili resulting in a very valuable wild- tate communication and leadership land fire safety resource. for the wildland fire community. The proceedings of all nine Since 1997, the IAWF has hosted Wildland Fire Safety Summits are nine Wildland Fire Safety Summits available on a single CD disk from at various locations in the United the IAWF for a nominal charge. States, Canada, and overseas. These Alternatively, they can be down summits bring together wildland In 2005, the International Association loaded from the IAWF Web site free firefighting professionals and others of Wildland Fire began publishing the of charge. For more information from around the world. Through collective proceedings of all their Wildland about the IAWF and their safety Fire Safety Summits onto a single, presentations, displays, and group collective CD disk. summits, consult their Web site at breakout sessions, participants
*Marty Alexander received the 2003 IAWF International Wildland Fire Safety Award, given to a member of the Past IAWF Wildland Fire Safety wildland fire community who has made a significant contribution to wildland firefighter safety, either direct Summit Locations and Dates ly on the fireline or indirectly through management, research, or cultural changes. Bret Butler has served as a proceedings coeditor for three IAWF Wildland Fire • Rossland, British Columbia, Canada, September 29-October 2, 1997 Safety Summits (i.e., 2000, 2001, and 2005). • Winthrop, Washington, USA, October 26-29, 1998 Dr. Marty Alexander is a senior fire behav • Sydney, New South Wales, Australia, November 2-5, 1999 ior research officer with the Canadian • Edmonton, Alberta, Canada, October 8-10, 2000 Forest Service, Northern Forestry Centre, • Missoula, Montana, USA, November 6-8, 2001 and an adjunct professor of wildland fire science and management in the • Luso, Portugal, November 18-23, 2002 Department of Renewable Resources, • Toronto, Ontario, Canada, November 18-20, 2003 University of Alberta, Edmonton, Alberta, • Missoula, Montana, USA, April 26-28, 2005 Canada. Dr. Bret Butler is a research mechanical engineer with the Forest • Pasadena, California, USA, April 25-27, 2006 Service, Rocky Mountain Research Station, Fire Sciences Laboratory, Missoula, MT.
Volume 68 • No. 2• Spring 2008 49 gU i d e l i n e s F o r co n t r i B U t o r s
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