 In February 2007, a diversity of 27 key interagency individuals, all highly familiar with High Reliability Organizing, HRO, participated in the Advanced HRO Seminar. Sponsored by the Wildland Fire Lessons Learn Center, the seminar's objective, to provide a deeper understanding of how to apply HRO principles, to promote ideas on how to best teach these HRO principles, and to help build wildland fire programs that consistently achieve their fire management objectives safely and effectively. Starting in 2004, the Wildland Fire Lessons Learn Center has sponsored three national managing the unexpected workshops on High Reliability Organizing. These sessions were all based on the principles of HRO developed by the two international experts, authors Dr. Carl Weich and Dr. Kathleen Sutcliffe of the University of Michigan's Ross School of Business. More than 300 people have attended these HRO workshops. Feedback from the successful learning events overwhelmingly confirms that HRO definitely deserves a place in this country's wildland fire management operations. The 27 participants at the Advanced HRO Seminar worked intensively with special guests, Professor Weich and Sutcliffe to determine the best way to apply HRO to actual work practices. As you will see, the seminar's overall goal was to help the wildland fire community teach and explain to spread the good word about HRO principles and mindfulness. If you had to say what's this, it's all this managing the unexpected stuff about, it has a strong piece of interpretation in it. By which we mean a lot of what goes on is the kind of labels that you put on top of something, what your biases are to see something happening. It's a lot about how you make sense out of situations. It has a lot of thinking kinds of processes in it, more so than a lot of people are comfortable with. There's action in there, but you need to be clear on how that works. We're interested especially in updating by which, and I think this would be an important thing when you're training trainers or when you're talking to anybody, one of the things that's really striking is that people differ in how frequently they say, let's take another look at this, where's the fire now, where's the crew now, how are our resources and so forth. Do we need to change the way that we're going at this thing? Some people do that on a rolling basis, keep doing it. Managing the unexpected for us would be making sense out of the unexpected. It has that further piece in it that says you got to see early things that are not quite the way you thought they were going to be because those may be signals or clues that things are starting to turn sour and that several different things are likely to fall out. So if you want to influence people, what you want to do is back it up and say, how are they framing this? How are they putting a label on this thing? Why did they notice this? Why did they have a blind spot for that? Why did they miss this particular clue? And once you get a sense of how that works, then you're likely to take appropriate action, make appropriate kind of decisions because you say, if somebody is in this kind of a situation, then they should do this. We should pull back, we should regroup, we should dig a line there and so forth. Fire seems to us an ideal situation because it is dynamic, it is active. All of the kinds of plans that you set in tend to get undermined by, quote, unexpected wind events and other sorts of things that sort of cover a multitude of sins. And that's fine. You say, whoops, I got that one wrong. There has been quite a bit of research recently on updating and it really floored me because I had assumed that if you simply say to people, look, you've got a picture of the situation. Is it still current? Is it still working? Is it still accurate? Recent research has suggested that most people update within a framework. They don't break out of a framework when they do their updating. And this is important for all of us because one of the populations that is poorest in updating outside of the framework are anesthetists who work during surgery. Things start to go wrong with a patient and once they see or once they label what they think is wrong with a person, they are really stuck trying to find things within that boundary that fit that initial impression. So yes, they update, but it's remarkable how narrow the updating is that's going along. They don't back out and say it could be a whole different kind of problem than what I'm looking at. So it is not enough to sit down and say, boy, you're home free on managing the unexpected if you just take stock more frequently. That's a first step. But you've got to then be sure that they're not stuck inside of a fairly narrow definition of what's unfolding and are looking at a wider variety of possibilities. And that's where listening to other people in a crew who may see it different. That's where rookies are sometimes helpful in the sense that they don't see it the way the veterans do. And they may notice something that the vets missed. And so you don't say, you know, you're green behind the ears and I don't want to pay any kind of attention to you because once you're seasoned then you'll be valuable to the crew. Probably true in some ways, but in other ways they may just be picking up stuff that you're missing that would help you pull out and do a richer kind of update than you did otherwise. One of the things that we want to keep our eye on is that, yes, you can talk about changing people's attitudes and then they're going to behave differently, but a lot of the stuff that we've been talking about has got that thing running the other way. And we want to think about doing an after-action review. You do it, you don't know why you do it, you're supposed to do it. People say it's a good thing to do it, but you go through those kind of motions. And then what happens after the fact is you start to develop some kinds of preferences for this, some kinds of views that it's instrumental or that it's helpful to do other kinds of things. And then you, in a sense, sort of act your way into thinking an after-action review is a really crucial piece of thing. But you don't just sit there and lean on people and say, do it, do it, do it. They just go through the motions of doing it and after a while they say, hey, this produces some things, I want to do more of this. So when we keep talking about how does this stuff issue in concrete things like how you get out of camp, how you do a briefing, how you do an after-action review, how you do a chainsaw after-action review, all of those kind of things, that's the specific kind of action that we're really interested in, not something in the abstract. So that's why it's really important that you talk about what you do, and then we can say are there ways in which principles about simplification or failure or whatever it is can be woven even more into that. Remember that we've got this separation where these five things, in the first edition, it's muddy in the sense that we talk about high reliability processes. And this time around it's clear that we're talking about five kind of principles that you want to have in mind as guides to things you might do differently day to day. That's where the practices things come in. So what it is that you run into on a day-by-day basis, you ask the kind of question that says if I took seriously the idea of trying to get up front with anticipating mistakes I don't want to make, or if I wanted to be aware of where I'm oversimplifying things, I would hold one more meeting or one less meeting, or I'd go up one level or I'd go down one level or I'd stay one hour longer or get out of there one hour earlier, or some kind of really nuts and bolts things in terms of your own kind of practices that would translate some of those principles into place. I am really focused on the practical application in a resistant culture. I find myself in the situation where if it wasn't somebody's idea, they didn't want to buy into it, and I don't, I hate to use the word buy-in. It's how do we get them to come on through dialogue. So that's what I'm dealing with and expanding it beyond fire. I'm responsible for fire, safety, law enforcement, all of those things in my region. And after participating and facilitating in Santa Fe, wanting to really look at it in our other operations, I'm also looking at how to blend the academic and the practitioner side of me. So how do we blend that? How do we, when we have those dialogues not sound like, you know, sound like, I want to sound like I'm, you know, in the field still, and how do we have those conversations without elevating it to the point where we totally lose them? Like you said, we get the blind look. And then what's the communication strategy? How do we develop how we're going to present it? How do I work with those people to bring them into the blends? I do a lot of teaching where I'm from. And one of the things that I keep telling our folks are that we don't manage fire. We manage people. And I see the book and the lessons that I've picked up so far from talking to folks. I see this as all about people and working with people and how to interact in a better way. It's also about, to me, it's about how to think without the shades or the lenses or whatever that made you see things certain ways before to be able to go for clear think or for a clear view of what the situation is as opposed to being led by your experiences in the past towards not seeing something. Tomorrow I'm going to be teaching Humboldt to Abbey line officers through some scenarios dealing with wildland fire use. And Dave introduced me to HRO years ago. Honestly, I'm starting to dislike the acronym HRO because it gets, I think, Paul said it, it hung up on terminology. So tomorrow what I'm going to try to do is incorporate some of these practices, you know, sensitivity to operations without ever saying the words. But at the end, you know, kind of, as I tell other folks, I slide the book across the table. I mentioned kind of, you know, HRO stuff. You might want to take a look at that. But instead of making it some sort of formal deal. But the challenge is, and the thing that has bothered me for a long time, is how do we improve our thinking ability to think about unexpected events, prepare for them to be ready to do those without a cookbook. So the HRO cookbook, I stay away from that. Sometimes I hear myself saying HRO or, you know, sensitivity operations, difference to expertise, blah, blah, blah. I see the volume go down, the shades go down. It's like, no, no, no. That's not what I'm trying to convey. What I'm trying to convey is a way to think logically about dealing with unexpected events. And I heard that across all the tables. How do we do that? Use Brett Faye's comment about being hung up on the terminology and wanting to talk about these practices without saying the words exactly. And I think that's really an important point to keep in mind. But one of the things that is fascinating, if you watch people who are really good interventionists, people who would be counselors, people who would work with other people, one of the things that's striking is that the frameworks that drive them never show up in the interviews. To give a far-fetched, it's true, but to give a far-of-field example, if you look at Sigmund Freud, for example, and how he actually conducted sessions, you never once hear all of that esoteric ids and super egos and inferiority complex and all that kind of terminology never, never shows up in any of that kind of conversation. Those concepts are running around in his head and he's mapping those on to what he's hearing or what people are doing, but that's as far as it goes. He doesn't train them in that particular terminology. It just helps him keep track of what's going on. I simply want to underscore the point that Brett made so that you don't say, I'm going to teach you about commitment to resilience today. Rather, I think what you want to do or what we want to try to have in mind is in some ways what Melinda was talking about, because the interesting thing that she made several points, but one of the interesting things that you said was a lot of the crews are already doing it without knowing that's what it is specifically that they're doing. Now if you're sort of coding that in your own mind, then you can say let's do this more often, let's do more of this, and you can use whatever language fits the crew. You don't have to use this kind of technical language to get on top of that. So I want to be sure that we're comfortable with the terminology and that we've got some ideas only because it sort of helps us keep track of stages in a process or things that we want to do. But I don't necessarily want people to have to use that terminology or feel it's one more terminology. And as Jim said, the burdensome of the list that you guys are carrying around in your heads and adding to is just overwhelming, and I don't know how I'd thread through that kind of stuff either. And I'd see HRO as one more pain in the a**hole. We've already got enough lists and now here comes five more of this. What this would mean was I have to do the other ones. We'll talk around those kinds of issues as we go along. But let's, in a way, use the terminology so that we can be clear what we're looking for in other people, but how we label it, what we spot, how we describe it to them, what we single out, we use the language that makes sense in those kind of settings. And we don't try to teach them an alien terminology, which, in a way, calls the attention to itself rather than to the kinds of things that are going on. People are using these labels, but they don't have a rich enough understanding or description in their heads to really kind of understand what they mean. And I think that's where the issue comes in, is that the labels, if people have a really rich understanding of the concept and what we're trying to get at, then you can use that shorthand label to kind of talk among people. But if you don't have that, then it's a meaningless label in a way. I mean, it does give you a language and there are many examples of organizations, for example, that have adopted particular movements. And I'm thinking about the quality movement, and I'm thinking about IBM, no, it was at Xerox, and it was Xerox Park in their research arm of Xerox. And they did a whole bunch of workshops, so everybody in the organization knew what the language was of this particular quality movement that they were rolling out, and it was really important because it did give them a way of talking about it, and they did a lot of training of people, so they really knew what was underneath the label. Let me just add to that that I would do probably precisely what Brett said he's going to do tomorrow, which is talk about things in their language, and near the end say, notice the kind of mapping that we've been talking about, five themes or five kind of principles. And then you may want to come back the next day and say, okay, did those five principles cover most of the things that we had talked about during the day, or did we leave some stuff out? Do we need a sixth principle, or is there a different set of principles that would work better? But I think, Ann, if you start out with the kinds of things that are meaningful for them, then you put the labels on, then you ask the question, what's the goodness of fit? Does it fit pretty well? Does it not fit well? If it fits pretty good, why not use the shorthand labels? But let's be really careful that we don't sweep too much under there and lose some of the things that make us a really terrific crew or a team that's working well in the field. And I really got kind of enthralled with the whole idea of intuitive decision-making, recognition, prime decision-making, to use the labels. And it was interesting to listen to you just now that you never used those, and it kind of goes back to the discussion of high reliability organizing and what breads want to do tomorrow and not using the term, but getting the point across. But it made me kind of think about where we are as an organization with decision-making and have we really pursued that. And I think we have, actually, to a large extent. And Emily has been gracious enough to host a couple of cadres and develop a cadre in the southwest to teach tactical decision-making through the use of sand table exercises that's come back into vogue after a little bit of a hiatus. But I think that's been successful and somewhat under the radar because it's been at the field level. And we've hit those single-digit GS folks pretty hard and got them to buy in. But I think what we've focused on with our work with tactical decision-making has been not getting the right decision because there's not necessarily such a thing, but really using that as an opportunity to talk about why you made the decision. And really bringing out the thought process behind. And this strikes me, actually, as a great opportunity that we can start incorporating some of the more of the principles of HRO into those decision-making games into the discussion without people ever reading it. If you think about it, it's impossible not to be doing something at all about failure, simplification, operations, resilience, and expertise. If you think of the opposite of each one of those, you're preoccupied with failure. Think of it as a dimension and at the other end is success. Now this individual who says, in essence, I'm doing fine without it, is doing something with that evaluative dimension. Paying attention to failure, paying attention to mixes of failure and success, paying attention to his successes, but that whole dimension has not simply dropped out of his existence. Same thing is true for simplification. Person may be saying, keep it simple, stupid, I don't need this kind of complexity, may be trying to put more differentiation and more complexity in there, but is doing some kind of differentiation or lumping to pick up Mike's phrase, lumping or splitting things. So the person is not simply indifferent to all of this HRO stuff. There's somewhere along the line there and what we've been saying is you want to inch them in one direction or move it along in one direction because it seems associated with more reliable and resilient kind of performance. You can think of the other three as dimensions. Think about fine, we've got operations anchored at the other end with planning and strategy. Somewhere along in there this individual is who says I don't need it. Somewhere along the dimension of resilience anchored at the other end by anticipation is this individual. I'm going to think my way through in advance and try to figure out every single thing that's going to happen and be prepared for it, or says I want to cultivate the kinds of resourcefulness that we have in this group. I want to know what kind of resources I've got in this group and I trust that we'll do something adaptive in the moment when something surprising turns up. Those are different kind of commitments. We've got three hours, we're going to spend three hours planning and anticipating. We're going to plan, spend three hours assessing what we're good at, what we know as individuals, how we could recombine some of that stuff. Those are very different ways to spend that three hours. I'll split it half and half if you want. The last dimension that this individual ranges somewhere on is that this individual defers either to experts or to authorities, to people higher in the hierarchy. When the individual says, I'm doing fine without it, that's nonsense because what they're doing is something about success, failure, something about the dimension of simplification complexity, something along the dimensions of operation strategies, something along the dimension of anticipation, resilience, and something along the dimension of expertise and authority. When you're asking yourself the question, where does this stuff apply? It's already applying in the sense that there's somewhere along those kind of dimensions. When David was talking about the biannual or two times a year operations meetings, he said we talk about behaviors we want to sustain and behaviors we want to remove or delete. And you remember, we ask him or I ask him the question, can you give me an example of each? And you remember there's a long pause in there and David's sitting there saying, God, I can't remember one and I'm trying and I'm trying. And then he came up with this really good one involving ignition and holding crews getting out of synchrony with one another. Point is that it's the very behavior that he worked on or the fact of a behavior that he worked on and came up with where we want you to be focusing your attention when Kathleen keeps banging on you to think about the recurring behaviors, think about how this stuff happens locally. I think that's pretty much what she means and the fact that it's tough to come up with that or you say they don't mean something that simple, do they? We do. And David hung in there with us and said, okay, this may not be much of an example. It was a great example and that's right where you've been talking at different times intermittently around the morning and that's where the question is, when those two get out of synchrony, are you sensitive enough to operations to pull that together? Are there any mechanisms that when they really start to get unsynchronized, they in the moment can bounce back and get back into synchrony or is there no way or no experience base for them to do that? And if you make a remedy to try to pull those two things back together, then you're working at that level and then that can spread out so that other relationships between the ignition and the holding team or the firing team in general or whatever may well start to develop as a consequence. So I think that's just a good microcosm both of what we have in mind when we talk about converting principles into locally meaningful practices. So I simply wanted to underscore that point plus the fact that that's just a good illustration of it. In my past, we have tried to introduce HRO principles to people that I've worked with and I used a couple of examples when I worked on the Malheur National Forest in the late 90s. I worked on a repel crew and I was also the forest lead fire refresher instructor and I was fortunate to have a fire staff that was a real progressive guy, very interested in HRO as well and gave me the latitude to teach basic HRO principles at fire refresher training for the entire forest for four years and then for the repel crew I worked on. And I describe some of the processes we used within our own crew to create mindfulness and sensitivity to operations and one of the things that we stress very hard on the crew I worked on was that no matter your position on the crew you may be the one that notices something important and it's important that you feel comfortable bringing up things that you are uncertain about or you're uncomfortable about and that we all have a responsibility to look out for each other's safety. And so we use an example of if you see something important going on and you don't report it you may create a larger problem later by not reporting that. So it was part honesty and part, I guess, buying into this group ethic that we looked out for each other we were mindful of what was going on and when a person was uncertain of a situation they would try to migrate that decision or decision point to somebody that maybe had a little better understanding. You know I can tell from my perspective of doing fire refreshers I felt that there was always a fairly small percentage of people probably less than 10% that really liked it and grasped on to it right away and wanted to read the book and all the rest of it there's probably about 50% that were somewhat indifferent there were a smaller percentage that were somewhat resistant and then there was a group that seemed to be really resistant to it that you know I don't want to hear this touchy-feely crap you're wasting my time but I think overall we had a pretty good success because when I went back on the forest last year they're still talking the talk they still are it's continuing on that there's people that feel it's important to continue to stress the kind of things that we're talking about resiliency, mindfulness, sensitivity to operations and all the rest and are using the terminology many of them have many of my former coworkers read the book and became advocates as well so how did you initially get people to start paying attention to it? well initially in the fire refresher training that was where we first started and I used some examples the aircraft carrier example I thought was one that resonated well with our group because of the danger level involved and the teamwork and all the rest of it and beyond that we also tied it into CRM principles you know at that time CRM was just starting to get on our radar and so we also you know discussed it in light of CRM also embraces that same communicative environment where people can feel free to self-report errors and that sort of thing so again the CRM stuff I mean you tied it with that but that was in formal training sessions or I mean the question is how did it diffuse and it was mostly through the fire refresher courses yeah and you know the way I conducted my refreshers was fairly interactive we would have you know talk about a subject and then have group discussion or you know we did sand table exercises and other things as well but you know for this portion it was essentially a power point that I put together on my own and then we had group discussion afterward we spent a lot of time talking about terminology and train the trainer and you know starting from some of the comments that Brett said yesterday you know how do we really go into this do we you know back into it with agency terminology and that way or do we come in right with the with the principles I made you know just some general thought about depending on what you're you know we always talk to our audience and start where they're at maybe the upper graded ones we start with the principles in the book and the ones who are really on the field start in with the back end so that's one concept we talked a lot about the role of the learning center and how they can you know you talked about the example file maybe they create a teaching file it's in one location and the train the trainers can keep putting examples you know there's one page here success here's what happened here's what worked what didn't so that we all have access to that and then a lot of dialogue around modeling the HRO principles and not just necessarily talking the terminology all the time but really what is what does it look like to people I had some examples started out what not to do and eventually worked its way into what I consider at least to be the start of a success and that was at Mount Rainier we had a helicopter crash in 03 a year before the MTU and Santa Fe I might add I'll just clarify that at the time I was going to school I thought I knew the answer to almost everything and my staff considered themselves lab rats so anything that I would bring into the workplace they were like okay what book are you reading this week and you know what checklist so it was learning really quickly what not to do and so basically I just quit saying anything in a way so during the helicopter crash there were a lot of issues going on with OAS and our aviation management at the park some good mostly not so good so we were really under the microscope and then we crashed a helicopter which is a really bad place to be and I know some of you are on the table going yeah we know after the crash there were a lot of things that led up to the crash itself and if we had stopped and recognized any one of those small things the helicopter wouldn't have crashed but yet we didn't there were some egos involved there were some different intentions involved after the helicopter crash there was a lot of lack of respectful interaction going on all the way around the investigation didn't help matters in effect created even more issues so after that occurred then we created all these checklists to ensure that quality assurance was at the hella base up to the incident command post they had to sign it then we had to sign it and in that way we know that everything was taken care of I'm sure you guys know what happened there the trust just went this way the communication went that way as well then I went to the MTU in Santa Fe and a little further in my studies and understood what I didn't know so then I came back and got rid of the checklist that wasn't in fact our aviation program was actually going downhill instead so we started having more meetings and working with people I was working off the audit checklists that are in the book and I was just rephrasing the questions to the aviation staff from those checklists and just asking general questions and it got to the point where we had removed ourselves enough away from the incident we were out away from the microscope and we started asking ourselves a week before the incident what could have we done different that would have led to this up to the day of the incident two hours before the crash what could we have done different and the dialogue actually started then they think the pressure was off and I think my terminology was different I don't think my intention was different but I think how I was approaching it was a lot different so what happened is they started seeing the smaller things as well and I started seeing things from their perspective more I was the one who took the hit for the agency because that was my role but there were things that I was sometimes when the focus is on us we don't see things very clearly sometimes so their use of terms and explanations allowed me to start to see things a lot more clearly so the communication started happening the trust started coming a little bit together but what happened is that six degrees of separation with that aviation workgroup I saw they're just not responsible for aviation they're members of the trail crew they're members of maintenance all around the park and what we saw is that they were taking those concepts that we were talking in these new aviation meetings out into the other places that they worked we had an issue with the trail crew with a lot of blown down trees and we were out there deciding how we were going to manage a huge safety issue and one of the trail crew members who was at the helibase that day said well what could go wrong with this if we're going to go here we're going to use the chainsaws we're in wilderness how are we going to manage all this what can go wrong in this situation and I just stood there and smiled because it was finally we're starting we're trying to pick out those small things but it was a huge learning curve and I did more things wrong than I did right throughout the entire thing but it's just I didn't use the terminology but I used the concepts and my boss and what Dave said earlier you don't have to always brief him but if you're a good manager I think good management leadership are the concepts in here and my boss said what's different now units working well what's different than when you first came in what do you do when differently and then I can pick out the concepts but it's not preoccupation with failure it is a teniveness to the small things just using our agency language to me that's one example of what started out not so good and then slowly working away and it was not easy because my staff was looking at me like okay you're going to throw another book at us and I had to really pull back because it's easy to get into that one you know it's the flavor of the week and you've got to be really careful and so I did some wrong things but I think in the end you know it's a better unit all the way around because of these concepts but they can't tell you that's what it is they still don't know several epiphanies here in the last couple of days and one of them has been that I think that carries that carries through to how you teach people you teach people by showing them where behavior exists talking about that behavior eventually leading them to what principle they're looking at eventually leading them to terminology where before yesterday I would have approached it from a completely opposite perspective and would have taught people the principle first and then worked down to where they could apply it in their daily lives I think this is a really great thing how much just how deep your knowledge is of these ideas and that we did start talking practice right away and I thought that was really cool and it was very surprising to me because I hadn't expected that it would go that way so clearly you really have a great understanding the people in this room do and you have a tremendous amount of resources that you can draw on so I think that's really cool one thing that I noticed is that in a way that you talk about practices a little differently than the way executives talk about practices and I can't quite articulate it but it's cool and I just really gained a lot this was a very energizing couple of days for me I've learned a tremendous amount and it's always a pleasure to be with all of you I guess the only other observation was I really think you know about everything I know now I'm serious I can't think of a thing that's been held back or that I know that you don't know so in the sense of of engagement or in the sense of just trying to match the kind of questions that you've got or the discussions point you've got with some kind of information I'm not capable to do much more than we've done today this sets a really tough benchmark for me on subsequent kind of occasions I'm going up shortly and I just think I'm going to have to those are going to be disappointments thanks to you guys