 7-1-1, just that I copied it. The fire has made some runs, you've had some significant fire activity and you have a road closure in place. It is a fact I think that predicting what a wildfire or a wildland fire use fire is going to do is a risky business because there's just so many variables. Yeah, I knew whatever air support I could get over here on the highway, we've got a big spot rolling on the other side of the highway. The uncertainty of what we deal with in fire and trying to predict what it's going to do and what it's going to hurt and what it's going to benefit is one of the things that keeps it coming to work every day. We've got a large spot fire. I need to get some aerial resources over here, pronto, or we've lost this thing on the other side of the enterprise. Never have we had more emphasis on describe fire, wildland fire use, as we've had these last number of years. Most of us who deal with fire, particularly wildland fire use or prescribed to fire, worry about that unexpected event, the event that all of a sudden puts into question your ability to manage. Get out, get out, RPO everyone, no! We all have experienced that feeling, whether with fire or at other times. It's that oh no feeling that you have just lost control or are about to, for a project that was expected to be manageable. Can we do better? Are there methods to help? This program uses a recent fire event to introduce how line officers and fire managers can implement new methods to better prepare for that unexpected event. Attracting our interest is a management method called high reliability organizing or high reliability organizations. HROs include aircraft carrier and air traffic control operations, emergency room departments, and some fire management programs. With these operations and for a wildland fire use program, the public has high expectations for reliability and expertise. We're going to have an extremely active day on this fire. HROs involved with high risk operations use five basic practices to prepare for or deal with unexpected events. Kathleen Sutcliffe, a professor of management and organizations at the University of Michigan, is a co-author of the highly acclaimed book, Managing the Unexpected. Based on research by her and co-author Carl Weich, the book has been heralded as a primer for exploring the processes and practices inherent in an HRO. The past settles its accounts and the idea being that the ability to deal with crisis situations really is largely dependent on the structures that have been put in place long before the chaos arrives. So that idea is that if we've established a set of practices, a set of policies, a set of procedures that we're adhering to that we're more likely to have an infrastructure in place that's going to enable us to manage unexpected events. Now the best organizations that achieve reliability under varying challenging conditions do the following five things. First, they're preoccupied with failure. Second, they avoid the simplification of their belief systems. Third, they're sensitive to operations. Fourth, they're attentive to creating resilience. And fifth, they create flexible decision structures. HRO practices are grouped into two basic concepts, mindful anticipation and awareness and mindful containment. Mindfulness refers to the HRO process and practices that line officers and fire managers can use to manage unexpected events or to implement a program that they and the public want to be reliable. Recently, the Dixie National Forest, located in southern Utah, had what might be described as an abrupt and brutal audit as they managed a wildland fire use event. The Hawkins Fire, a wildland fire use ignition, started benignly early in the 2004 fire season, but quickly grew to a size and complexity that was not fully anticipated. We had two or three or four, several other wildland fire use events going at the time when Hawkins started and I was starting to feel pretty good about that this was a really good time to do that. Then Hawkins came along and it kind of acted differently than the other wildland fire use incidents that were going on in the forest at the time. And so we needed to react to that fairly quickly and it really did move fast and burn hot much more than we were necessarily initially prepared for, but we were able to prepare ourselves as that was happening. On July 28, at 1837 hours, two fires in close proximity, Hawkins 1 and 2, were reported in Oak Brush on Lost Peak. Active fire spread was reported within 30 minutes on one of these fires. At 2230 hours, Dixie National Forest line officers, fire managers and cooperators decided to manage these fires as a wildland fire use for resource benefits. The complex at the time did not threaten private property or structures. It was anticipated the fires would benefit wildlife and livestock by improving habitat and forage conditions. A smoke management plan approved by the State of Utah was in place. A Type 4 incident commander and a wildland fire use manager were assigned to the incident. By the next morning, a wildland fire implementation plan, stage one and two, was signed and implemented. Early that afternoon, the two Hawkins fires burned together, growing to an estimated 1,000 acres. Throughout the remainder of the day, the fire moved uncharacteristically and significantly east. It increased in intensity and pushed five miles east. At 1,900 hours, it crossed the planned management action point called the General Steam Road. The incident was approaching that dreaded, oh no, moment, and a wildland fire use management team was ordered. On the next day, July 30, low humidity and afternoon winds resulted in extreme fire behavior that pushed the fire to the north and outside the designated maximum management area. Fire managers from the Forest, BLM and WFU team declared the incident as an escape and moved to a wildfire focus with suppression objectives and strategies being implemented. A Type 1 team is ordered. At 1630 hours, the fire was reported burning one mile from structures. Pine Valley District Ranger Bevan Kilpac conducted his first of several town meetings in the nearby town of Enterprise at 1,700 hours. Smoke and fire were clearly visible from town. By August 1st, the fire was at 34,000 acres, with 680 personnel assigned under the direction of Martin's Great Basin Type 1 Incident Management Team. Due to early morning thundershowers, the fire behavior moderated. Nine days later, the fire was 100% contained. No structures were lost, and the fire stopped one mile from town. The Dixie National Forest Leadership, both line officers and key staff, quickly began to review the event. Rather than brushing it under the carpet or casting for blame, they demonstrated outstanding leadership by asking the questions of what happened overall. Why did certain things occur, and most importantly, what could be learned from this event and ideally shared with others who have or could face the same outcome. Essentially, an after action review. From the green area, it actually went all the way over here that evening of the 29th. The staff ride was organized and facilitated at the site where interagency and community leaders discussed the events of the incident. Staff rides, it's the best learning tool that I've come across in a long time. They can be scary, because you know, you're showing your knickers to everybody on what's going on with that incident. If you're doing a good staff ride, you're telling them everything you were thinking. You were not holding anything back, and they're there to judge you. Any time you're being judged, it's scary. But the best way to learn for the staff rides, and it's a little bit selfish reason on my part, is every time I replay those things again, I learn something else. There was a lot of interest from folks who were on other units to go down there, see what had happened and why and what they could learn from it as well. So I was kind of excited about it. So often, we're always so busy planning the next one, looking forward to the next one, that we don't take the time to stop and say, what did we learn from that one? What would we do differently? And to me, that's a really important question. Five thousand when it crosses it. It's impressive that the Forest Service decided to do a staff ride. And in fact, if we think about this preoccupation with failure, the idea that you want to examine things gone wrong as a window on the health of the system, you can say that this was a really great thing, particularly that people didn't go into this staff ride with the idea that we're going to try to find blame. The idea was that we want to find out how we can do things differently. What can we change for the next time? Did the fire actually hit our burnout operation? Staff rides and AARs are tools that exemplify those HRO practices of paying attention to close calls and near misses. HROs regard close calls as a potential danger rather than as a success or ability to avoid unexpected outcomes. These events provide important information on their organizational preparedness and capability to handle the unexpected. They use small failures as a means to avoid big failures. Very active. Yeah, there's a nice little pocket of fuel there. There are a number of expectations that is that nothing will ever go wrong. And to me, the wildland fire use program is an extremely complex endeavor. Can organizations achieve reliable outcomes repeatedly and avoid adverse consequences that may result from their actions? Is reliability an oxymoron for wildland fire use? A lot of organizations want to focus on success. These are organizations that pay more attention to failures, not only what they don't want to go wrong, what they want to go right, but also the small little failures that are going on in their organizations that give them a window on the health of the system overall. They're organizations that know that we have to bring a lot of different perspectives to bear on problems. You oftentimes hear the adage to keep it simple, stupid. These are organizations that realize that you want to complicate people's beliefs because it enables us to see more nuances in a situation and more ways that the situation may be going wrong from what we expected. They're organizations that put a premium on being sensitive to what's going on in the here and now. What's going on today at this moment? If we know what's going on right now, we can forestall a lot of small problems that are growing and when we deal with problems early on in their stages, we have many more ways to solve them than when they grow bigger. They're organizations that try to anticipate as much as they can the kinds of problems that they don't want to come up. They create standard operating procedures, they create plans, they create contingency plans, etc. But they also know that they can be surprised and so they try to develop the capability for resilience. And finally they have flexible decision structures and what we mean by that is that they know where the pockets of expertise are in their organizations and they defer to those experts when the need arises. And so the decision making might go up in the hierarchy or it may come down in the hierarchy. The term high reliability conveys two points. High risk and high effectiveness can coexist but it takes a lot of work. Achieving reliability essentially means achieving reliable outcomes no matter what the conditions. Mindfulness is the pass key into high reliability organizing. Staff rides, attention to close calls and near misses and having flexibility are all HRO practices that enhance reliability. Hawkins is a great example of chaos, that there was an expectation that the fire would unfold in a particular way and the wind changed several times. The plans had to be revised three, four, five times, six times. There were developments happening on the ground in one area that other people didn't seem to know about and people were giving the community some pieces of information when the situation was actually changing. Fire, wildfire, wildland fire is something that we've been taught over the years that we may be able to control. Well it's not always the case. It's very unpredictable. It'll do what it wants, when it wants. We've got some tools that help us predict where it's going to go but it's still a wild event. The public trusts us to implement sound reliable programs. Yet we have unexpected events that create challenges for us and upset the public. Can we do better by using HRO practices? If people are joking and they can't breathe. When I was down visiting the Dixie I was really impressed with the organization that they had developed. For one I think they had a deep respect for each other and that meant there was a respect from by one agency, a respect for the other agency. I could see that people were really used to communicating very frequently and very honestly. Go into wildland fire use. I think that those are prerequisites for high reliability organizing. The most active part of the fire. Did the Dixie National Forest and its partners perform as an HRO? Let's go back and look at those basic processes that HRO's practiced to achieve mindfulness and maintain reliability. Leadership had sensitivity to operations which allowed a commitment to resilience when the situation rapidly evolved into an unexpected fashion. As that happened they showed difference to expertise and had in place a flexible decision structure that brought in partners to share the risks being taken. They did start with a good plan and when ignition occurred they were ready but things changed. Today communication and relationships are strong. There's a lot of risk that potentially is there as opposed to just going to a simple confinement strategy under suppression. It takes dedication from a line officer and wanting to do the right thing to let fire work its natural role in the environment and to try and manage it but we need to be ready that you can't run a 100% risk-free environment not when you're dealing with fire. With a staff ride, a preoccupation with failure concept, they continued to learn and today they realize there is more to learn. They did not stop with the we survive this event and now we can just move on. Instead they kept learning and continued to learn, adopt and use the concept of its hard work because HRO's have or use a continuous process. They fight that human tendency to just check it off and say we're done. They continue today with what is a clear use of practices and procedures necessary to be an HRO. One thing that is impressive about the fire organization is that you are implementing many of the processes and practices of high reliability organizing. But I caution you because I believe that there is always more work to be done and that this is something that you never get behind you. High Reliable Organizing is gaining ground with fire leadership who are beginning to see that it is a process and a practice that has merit for their programs. The Hawkins event illustrated many practices of high reliability organizing. These concepts can be used by other land management agencies to improve their wild land to fire use programs. There are many ways to get started. I would take the five practices and simply start, but before that I would try to establish two preconditions. One is I would try to establish dense communication between myself and other people. And that's other stakeholders with whom I know that I'm going to be working a lot. I would be developing relationships and really creating a dense web of communication. Second of all, I would really be working on developing trust and respect within my unit and with other people because people are not going to report honestly or be willing to express their opinion honestly unless they're in a situation where they feel like they can do that. They trust other people and they trust that they're not going to be called on the carpet or ridiculed. It's not really hard to get started. I mean think about paying attention to failure. What is it that you don't want to go wrong? What is it that you expect to go right and how is it that that can be disrupted? How is it that it can go wrong? And the second aspect to that attending to failure is what are the small little things gone wrong? So for example, you're having trouble with dispatch or you're having trouble with radios. Two engines. How can we get a number of perspectives to bear on this problem? So avoiding simplification. Creating groups or group decision making processes that take into account everybody's view. Using the nominal group process where people who are low status get to express their opinions through a variety of means. Watch if we're going to try and do some work up here. Being sensitive to operations. Knowing who's doing what at different times and how can we make adjustments so things don't blow up. Creating a resilient organization. Making sure people have multiple forms of training. That they know how to do more than one thing. Making sure that you understand who your experts are. So when you have a problem, decision making can go to that person. We have immense challenges to restore fire and reduce hazardous fuels. Wildland fire use plays a key role, but one not without risks. Therefore we need to seek out and use many ways to improve our skills, our reliability and our performance. High reliable organizations provide a set of proven processes and practices that can help managers operate reliably and safely in a dynamic environment. There are many good tools to use. It's now your option. We should aspire to the characteristics that are described when you look at what a high reliability organization is. They're competent and they're flexible. We have a lot to learn by looking at those kind of characteristics and comparing it to the way we perceive our own characteristics and moving in that direction.