 We had ordered this humongous helicopter, biggest one we'd ever seen on the refuge, I think. Had a 450 gallon bucket. And we flew over the fire area and the refuge manager asked the pilot, he says, Can you put this fire out with this helicopter in that big bucket? He says, a piece of cake. And so he dumped a 450 gallon load on the fire and it didn't do much. He dumped another load on it and it didn't do much. We brought it the rest of the day. We had crews in there in the swamp along. We had this little old line going into the swamp where he'd dump a bucket and they'd get in there and they'd try to mix the water and stuff around. And the fire got suppressed but I don't think that we or the helicopter had much to do with it. And we've had fistfights. Our refuge manager and our gold folks have stood between people, between a division group super and ops chief and landowners because they felt like they were going to burn their property to a smithereens to stop the monster. And we just don't have to do that anymore. How do you manage for the unexpected in the complex and sometimes fire-prone 438,000 acre Okifanokiswamp ecosystem? What concepts, tools, and skills do you need? What should you be paying attention to and watching out for? This was a key challenge facing more than 100 members of the Wildland Fire community who traveled to Jacksonville, Florida for the second national Managing the Unexpected Workshop on High Reliability Organizing. On the workshop's first day, setting the tone for the entire week, the two people heralded for helping develop the concept of High Reliability Organizations, or HROs, explain the concepts and strategies behind High Reliability Organizing. Dr. Carl Weich and Dr. Kathleen Sutcliff, renowned organizational psychologist and eminent University of Michigan professors, are the authors of the insightful book Managing the Unexpected, assuring high performance in an age of complexity. Several weeks before this special 2005 workshop, all participants were mailed Weich and Sutcliff's Managing the Unexpected Book. Dr. Weich and Dr. Sutcliff emphasize that the same five key processes or hallmarks surface again and again in high reliability organizations. A preoccupation with failure, a reluctance to simplify, a sensitivity to operations, a commitment to resilience, a deference to expertise. Using these five High Reliability Organizing Principles as guide, workshop participants used the Okifunoki Fire Management Program as a field visit HRO case study. Most importantly, workshop participants wanted to see if they could take their Okifunoki Swamp case study insights, they're managing the unexpected learning moments and apply them back at their home units. A major goal of the Okifunoki National Wildlife Refuge is to use prescribed fire and wildland fire use to reestablish the Swampland's historic and vital fire regimes. Managing the unexpected workshop participants learned how this unique and multifaceted Okifunoki Swamp ecosystem represents a complex landscape of wetland and upland habitats. As they prepared for their field visit, the central question before the workshop participants became how do these swamp fire and resource managers manage? Tomorrow we're going to be observing collaboration among groups and different kind of agencies in a complex environment when we observe the evolution of the fire management system program in the Okifunoki ecosystem. Pay close attention when we're hearing things, when we're watching things, when we're asking people questions, when we're hearing them tomorrow. Pay close attention to what are some of the mistakes they don't want to make and ask yourself how have they designed themselves to avoid making those kinds of mistakes? We want to keep our eye on mistakes they don't want to make for which they may not be well prepared and by less well prepared we mean that given the mistake they want to avoid they haven't identified cues that would suggest that their system is moving toward that mistake. That's the preoccupation with failure. What kind of cues, indicators, indexes are they looking at to see whether they're in pretty good shape or it's getting kind of sour and they need to pay some attention to it. Maybe they're using overly simple categories that will keep them from seeing some of these mistakes. Do we see examples of that or not? Maybe they have a weak grasp of operations that set the stage for a mistake. They don't want to make that mistake but they aren't really well set up to avoid it because they don't see the operations that might lead up to there. Are they unprepared to recover from mistakes? As Kathy said, we all make mistakes. Okay? Are they aware of that fact? How are they prepared to recover from them? Do they know their kinds of capabilities and their capacities? Or are they taking it as an article of faith that anything comes along we can handle it? Or a can do culture? Okay, are they or aren't they? You might also want to ask yourself the question and I hope you will because this would help to crystallize things for you back home. Are there parallels between the challenges we hear about tomorrow and some challenges you've got back home? It's an obvious kind of point but they may be tackling some of the same kind of things that you're trying to deal with. How are they doing it? What's worked for them? What hasn't worked for them? Use that as a kind of virtual experience so you don't have to go through yourself some of the agony that they may be going through. Take note of those things. Listen tomorrow for are they learning anything from their past experience? Listen for what their primary expectations are. If I do this, this will happen. If I do this, this will happen. See whether or not they are set up to see when those expectations might not work because the one thing we know is that when you have an expectation you really tend to look for data that confirm it. It is really tough to have an expectation and then say I'm going to look for all the reasons why my expectation is wrong. Yet high reliability organizations are able to do that. Ask yourself the question if I were to take charge of this program, the one we're hearing about tomorrow, what would you personally do more of, less of, and what would you keep the same? And probably most important of all, just keep tabs on what surprises you. I mean, you might want to make that concrete and this would be a tip that I would give you just in terms of monitoring failure and so forth. Write down if you can tonight what you expect you're going to see and learn tomorrow so that you're committed to something on paper. Go, really soak yourself in the experience tomorrow. Come back to your list tomorrow night and say whoa, I thought it was going to be this. It wasn't that at all. I thought there'd be this, yeah, there was that there. And all of these other kinds of things. And be sensitive because as Kathy said, this is a really fleeting notion, but this is a learning moment. For a short while you'll be surprised at the way they say something, at the way they point to something. You may say to yourself, why the hell did he point to that and why is he talking about that and not about this? Pay close attention right at that moment and catch what it is that surprises you because you and I are just too damn skillful at smoothing over something like that and say, oh, I can sort of see how he'd do that. And then you're right past that kind of an event. But if you can catch those small surprises as they go along, they're really golden things to pursue after that. Workshop participants have now had the opportunity to explore and hands on detail from the HRO experts a framework for high reliability organizing. It's time to apply their HRO insights to the Okifunoki Ecosystem Fire Management Program. This all day case study excursion includes a presentation on the Okifunoki National Wildlife Refuges Fire History and Prescribed Fire Program, an up close and personal tour of the Okifunoki Swamp Ecosystem and introduction to the related fire management roles of the Georgia Forestry Commission, the Florida Division of Forestry, the U.S. Forest Service and U.S. Fish and Wildlife Service. One of the first field visit speakers that day was Ron Furnettin. Recently retired, Ron served as the fire management officer for the Okifunoki National Wildlife Refuge for almost 30 years. We also learned that each habitat has its own particular set of problems. For instance, managing fire within the Okifunoki Swamp is different from almost any other habitat that we have in this country, including the cultivated bogs up in Michigan and around the lake states and in the northeast. Well, these lessons are all not new. In fact, history shows that we often learn them over and over again. The problem is that wet and dry periods and the resulting difficult fire years tend to occur in cycles. In this area, these cycles tend to occur every 10 to 30 years. During the period between cycles, entire management staffs can change. Priorities change. Current management plans are replaced and the files that tell our history are in the archives. That's why we're here today to... We have to document the lessons that we have learned in the past in a form that will survive through maybe long periods when fire suppression isn't an emergency and when everything just becomes kind of mundane so we can remain ready to cope with the year when it once again becomes a major priority. These are fires that occurred during the beginning times before the refuge was established between 1855 and 1927. Now back during this period, the fire management managers kind of had this little rule. When the swamp water level was high, they make the best use of the swamp they could and do everything they could to try to run the fire into the swamp so they had one less line to worry about and the fire would go out on that side. When water levels in the swamp were low, if they had a fire on the upland, they'd do everything in their power to keep the fire out of the swamp because they knew that once it got in there we were in for a long period of trouble. Well, in closing, the lessons we learned as one, we can't safely manage fires without adequate fire suppression equipment, personal protection equipment, training and funding. Two, it's impossible to suppress fires in the swamp other than a very small spot fire. Three, it's dangerous and foolhardy to put personnel in the swamp. Travel is hazardous and difficult and personnel may easily become trapped. Four, it's dangerous to put equipment in the swamp. It will get stuck. And if you could put, five, if you could put equipment, personnel and anything you wanted to in the swamp, it wouldn't do any good anyhow. The helicopter drops in the swamp. This vegetation layer is so thick that it atomizes the water when it hits it and it doesn't soak the actual burning area. You'd have to dump buckets and buckets in a single spot just to put out a little piece of fire. Seven, retardant drops just make a real good show besides fertilizing the vegetation that's there. Eight, if it were possible to create a fire line in the swamp, the chance of it holding anything is zero because there's too much burning stuff in the air. Nine, as they did in 1932, the most effective management technique is to retreat to the upland and fight fire when it gets there. Ten, managed wildfire used in conjunction with prescribed fire is beneficial in the uplands and in the swamp for both fire suppression and habitat quality. Eleven, the surface fire in the swamp stops spreading only when it reaches an open water area and twelve, the fire isn't out until the water level comes up from underneath. And as a result of all of our planning, we did finish the swamp sedge break around the rest of the swamp and Fred will tell you more about that. We developed a plan for when we would fight fire in the swamp when we wouldn't and we've also developed a series of dip sites throughout the swamp so that we can use helicopters to help us when the fire comes to the upland. The Okefenokee is a land of earth, water, and fire. If you take either of those three elements away from the mix, you changed it forever. What I want to give you briefly is just an overview of what we have to work with in terms of resources that brings us up to why we have adopted the policies, the procedures that we have to manage wildland fire. On our uplands, our long-range goal around here is to restore the long-leaf pine wiregrass community back to a pre-settlement condition before Walmart. Parking lots, roads, trails, clear cuts, anything that manipulates the environment that prevents fire from flowing freely through the ecosystem at will once it gets started naturally. We have a very scattered management base, 16 forest management compartments around the outside edge, and numerous wilderness islands that have that same component of long-leaf pine wiregrass slash pine-pine mixture of about 17,000 acres. So, at 30-some thousand acres, we have to work with its upland component out of the 396,000 total acres, so you see most of it is swamp. We do management out there. We prescribe burn for the reason that Ron was talking about that these wilderness islands are upland, Fuel Model 7, okay, Southern Ruff. The fuels around them in the swamp burn more irregularly with greater intensity, and if the islands are not prepared to receive that fire, this habitat, which is endangered species habitat, could be destroyed very easily. So, we manipulate that by burning regularly so that then when the natural fire moves out of the swamp and crosses these islands, it does it at a much lower intensity, and we do not lose the habitat that's so fragile to the endangered species red-cockaded woodpecker. We have developed a fire use guidebook that will guide managers when they come here through the whole process of all the fire use documentation that you need to do. That has been looked over and approved while our fire management plan is now in review and will go through the NEPA process shortly with our comprehensive conservation plan. So, hopefully by the middle of the summer we will be able to use fire use in name. Everything we do here is fire use. We've been doing it a long time. Fire use has just kind of caught up with what we do. We didn't do it intentionally. We did it because that was the only way to do it, and we adopted that process. Sometimes fire puts us in a pinch, as we all know. The urban interface is encroaching in on us on all sides, and it requires us to be better managers and better prepared for when that fire moves out. And you notice I said when, it's not if. It will move out of the refuge onto private property. We know it will. That's why the Goal Organization was built. We knew within ourselves that there was no way to stop it. The best thing to do is be prepared when it comes out. We, the federal government, does not draw our boundaries anymore at the boundary line. We reach out to those areas around us that influence what we do and what we say. This is all state land. This is state land. So we have a couple million acres of land that has the core group of public lands that are surrounded by private lands, all working toward keeping their lands from burning and allowing our lands to have the best practices on them possible. Start small with an organization. Be content to just have one or two people involved. Don't set too high of goals for the group. Don't put Uncle Sam in charge. It's the worst thing you can do. Let the landowners let other folks run the process. You provide what you can, but let them run the process for you. And you be an equal member with the group. Set obtainable goals. Remember that the route taken is not as important as your destination. We want to start thinking about not building a fire management plan for the Fish and Wildlife Service or for the Forest Service, but we are for the state lands, but we want to build one that encompasses the whole area that looks at the things we've learned, the things that we've learned that we don't want to do anymore, and ways that landowners can grow their timber in harmony with that type of process. Many times the rows go perpendicular to the side of the refuge and when there's a fire, tractor plows go. You don't want to ride them because you're bouncing like this with those trees and you're knocking down trees. And so we want to turn things sideways and look at things a little bit differently. And our big goal when we first started working with these things was to provide a way to cut down on the confusion during initial attack. We all know it's a Chinese fire drill most of the time. No matter how well you prepare, as soon as the troops leave the barn, the radios don't work, you break down, nobody knows who's in real control because there's two or three. And so our goal was to try to provide things to this group that could do that and also provide information in a real quick manner to the crews on the ground. Fire use, we've trained five of our employees, two fishing wife service regional employees in fire use, four state and we sponsored state people, paid for them to go to fire use training and two forest service folks have gone so that we as a group begin to learn the new techniques and the new procedures so that when we're out there managing a fire use event, the tractor operators aren't cussing us wondering why we're out there because we're moving people into their organization that can tell the story of why we're out there and why we're doing it because their key people have the training and know what we're doing and we integrate them into our process so that they don't just have responsibilities on the outside, we bring them into the umbrella and they help us manage the whole thing together with that knowledge. We have 200 miles of road around the refuge that's designed to provide access and there are no mountaintop vistas, there are no real stream beds that you can follow to know that you're in this valley or whatever. It's flat and you can't see anything because there's trees all around you all the time so we had to come up with a way to make that road, the perimeter road usable and yes, those are bullet holes. It's a multi-functional sign, it provides target practice as well as... But you know, the landowners are embarrassed and they've started charging the hunting clubs to replace those signs. We don't have to do it anymore. It's their signs on their road and they want to make sure they're responsible and so they're replacing those by making hunting clubs pay for them. I thought that was pretty neat. And then we're sometimes a very long way from a paved road where the fire crews would come in and so the state of Georgia came up with the idea to let's put signs into the perimeter road and back out again and those are our hub roads all the way around the refuge so that you're on the road, our shift plan, shift plan, boy I said it there, Incident Action Plan will, boy, we'll say that you go in on Joe Cone Road, we'll have that flagged and you'll turn there on that red road and there'll be arrows all the way to the perimeter road and from the perimeter road they all come back. And so it's a really neat safety item to get folks in and out in the most appropriate, because there's 100,000 roads that you can get lost on around this place. There's been so much consternation with Incident Management teams wanting to do standard practices on this fire because that's the way it's always done and we've had fistfights. Our refuge manager and our goal folks have stood between people, between a division group super and ops chief and landowners because they felt like they were going to burn their property to a smithereens to stop the monster and we just don't have to do that anymore. And so we want to look at trying to help get our folks to maybe go back to short teams and train those folks in short teams into fire use so that they can come with a short team and manage it and not bring 60 people with them and nobody in the field. If you can imagine something going terribly wrong in the future, I mean, the worst case of tragedy, what would it be? Well, for us, we've got a state park sitting out in the middle of the swamp, which is wooey type related. That's always of concern to us to have a fire go there before we know it exists. A lightning strike in the middle of the night and it runs across the state park on us. That'd be pretty tough for us to handle. There's not a thing you can do about that. Other than we're burning the state park and if we had burning conditions today, we'd be out burning around their cabins and all that kind of stuff like most of us do for urban interface. But really for us, I think with the technology that our folks have got in terms of plowing out fires, we're going to catch one fairly quickly as it comes out of the refuge. But smoke is our worst nightmare because we've got Jacksonville, we've got Waycross, we've got all these metropolitan areas around us that our smoke will just lay on. And one of the things that our information folks should tell you today at the Boardwalk is that we have a tremendous information dissemination process. We call governors, we call senators, we call congressmen, mayors, school superintendents. I mean, the list is huge. Faxes, updates. We have people calling us as I've been watching the weather and you said that if we got a wind shift last week I might not need to have schools. Should I cancel school tomorrow? Yes, you need to cancel school. They'll shut their school system down based on what we've already told them. It's pretty neat, but it's the smoke that gives us our worst concerns. As the workshop participants continued on through the field study visits various stops that day, speakers from all the cooperating agencies, the Georgia Forestry Commission, the Florida Division of Forestry continued to voice a common united theme. The Goal Organization serves as a vital bridge that bonds the private landowners with the state and federal land managers in caring for these unique Okefenokee Swamp Area lands. Private landowners also shared their insights about the Goal Organization. A private landowner has always been in the Goal Leadership Role. Back in Jacksonville the next morning it was time to discuss high reliability and lessons learned from the all day Okefenokee case study field visit. So the whole purpose of Kathy and I kicking things off this morning is really to get attention back on your home organization so that you can take some of the ideas that we talked about on Tuesday used yesterday as a kind of platform to say and to think about just what sorts of things you might want to change or you might want to strengthen or you might want to do differently when you get back home. First point I want to emphasize is that these principles of high reliability I want you to be thinking of those as a language that can help you label and understand and think about and redo some of the kinds of things that you already are working on. So think about it as a language as a set of terms as a set of ideas that you can use to hold on to certain actions and activities that you have. Fred Wetzel yesterday gave us a perfect example of just what I mean by that. Fred said you know we were doing fire use without having a name for it. Then we got the name of fire use then we could think about it more explicitly we could do something about it and that's exactly the way in which I think you want to be working with some of these high reliability ideas. And so now what you do is work on being conscious of those kinds of high reliability principles fire use principles the way Fred Wetzel talked about them and now what you're doing is working on them so that you're good at them but you're also paying pretty close attention to them. And then finally what you want to do is have them so much a part of your routines and your activities that you're doing a thorough scan of situations. You're doing continual kind of updating you're doing the sorts of things that we're talking about that go along with mindfulness and high reliability yet at the same time you're not having to use up scarce attention to monitor them. One thing I want to be sure to re-ster and emphasize is that when we're talking about reliability and this came up in a number of discussions since Monday when we're talking about reliability we're talking about reliability through flexible action through having options reliability through resilience it's easy to get caught in the trap of saying to yourself look by reliability I need to be able to do the same thing automatically over and over that's to miss the point. The point is you want to do the same kind of scanning of a situation you want to keep looking at things and processing them in a mindful fashion but you want to keep as much flexibility in your actions as you possibly can deal with the unexpected events that come up. That's why there's all of this emphasis on small signs of failure early clues that things are going sour all of those are about trying to address a situation when it's pretty tough to see what might be going sour but it's really easy to cure it when you do see it. In fact, you've got a lot of pre-cocted physicians that's a kind of dilemma that they're in all of the time you want to get a disease at its earliest stages because then you got the best chance of curing it but the signs of it are subtle, they're small they're easily confused with other things and by the time you've got a nice full-blown sickness on your hand it's a monster to try to get a whole oven cure an earlier warning of things and that's what a lot of this mindfulness activity is about. This is a good chance to make points or to comment about just the issues of context if you think about the swamp itself as a pretty bounded kind of it is a bounded activity if you think about everybody rallying around doing a perimeter road if you think about fires moving in this direction are not trouble fires moving the other way can be trouble you've got a nice clean boundary around this problem in the way some of the rest of you don't those things may contribute to helping them build the level of collaboration that they have and you might want to keep your eye on your own situations about what are equivalent kinds of things that you could capitalize on that would give you a common focus or a common starting point or some place that you have a common set of interest that you can start to get people linked on remember one of the things that was mentioned yesterday is you don't have to have a big deal to get some dialogue started if you can just get some dialogue started over any old thing and get some agreements then in the data are good on this that you're building your way out and get agreements on a larger set of issues and don't settle for the easy thing which you hear all the time we hear it all the time executive programs or wherever Kathy hears it all the time when she's with doctors she goes in she talks some about high reliability organizations and the doctors just put the arm out and they say look we're different we're not like that we have our own kind of problems everybody's unique unique unique unique it's as if some people have staff in line but you guys don't have staff line relationships other people have division of responsibility and division of labor but you don't have them of course you've got them there are some kind of commonalities that we've across all of these sorts of situations and those are the kind of things that you have some leverage over and those are reasons why you can learn from some of these apparently organizations because they run into some of the same kind of organizing issues that you do so fine you're different we understand that we learn that over and over when we just walk around with you and listen to the kind of problems you have but we hear some of those problems in other settings at the same time so keep your eye on context but understand others have been down some of the same kinds of the others get entrapped the same way you do we're here in this room to learn about managing future unexpected events that could come and snap us in the rear and what I was left with and I just toss it out rhetorically to the whole crowd here is how do you pierce that veneer that crust to get down and start talking about those things because I don't want to talk about them in Region 4 I don't want to tell the Chief of the Forest Service oh yeah you know we've had three near misses last year with our program how do you have an audit a brutal audit that somebody described and yet it's respectful you know one of the first things that comes to mind on that is that going back to Carl's outline here of going from something that is unconscious and incompetent to unconscious and competent is what essentially what you're talking about is those middle processes or you're saying essentially and it would be interesting to try this just to be honest and to say we're at this conscious incompetent stage but we know it and this is the process by which this region or this organization is going to be moving towards the conscious competency these are the actions that we're going to be taking we are committed to this this is how we're going to measure it this is how we're going to report it so it does make you vulnerable but it also opens you up to obtain that leadership commitment to helping you move forward with that change process let me comment just quickly on one of Dave's point Dave's questions yesterday for my money I learned a huge from the first Ron Frenett presentation because what he was doing was saying wow we did this we had this wonderful brainered helicopter and it was out there with 450 gallons and damn it didn't do a thing when he could have been in a real box and said god we put that much money into the thing it's got to do something good so then you justify it and you talk it up and so forth and so there was a way in which the person who's got a hold of the history of things is saying gee when we saw a fire burn through a previously burned area we saw that it burned differently we heard a tremendous number of different examples of a learning organization just in that first episode so maybe one way that you can do it is just to back up your history again and you say boy in the 80s we were really in trouble and we've sort of understood more about how things burn in region 4 or we kind of see how to deploy people a little bit differently but take some of the heat off of right here and now and look back at some kinds of progressions that you've made and I thought Ron's presentation yesterday was really terrific in just laying out some of those kinds of things and also there was a real tone of just saying well we fouled up a good minute and then we moved on a little bit from that and that's the piece that you want to be able to talk about and maybe if you can talk openly about your distant history you can move it up a little closer to the present a little closer to the present and then you can start to look with more candor at some of the kinds of present kinds of difficulties. A thread that I noticed running through the conversations yesterday was the deference to expertise and the reliance upon expertise and I think that in that community is also reflected in the various comments that we've heard in terms of the longevity of the people in the area there's a lot of stock I think placed in the expertise of the local folks and I think this is one of the aspects that has developed the trust over the years as it we're dealing with the same we're dealing with people that we know that they know what they're doing we trust them to do that and they are the recognized experts in the area I think a lot of the controversy through the 80s when command teams were brought in was the failure to recognize and rely upon local expertise and this is some of what created some of the hard feelings during some of the fires the friendly fire was not all that friendly largely for that reason the local folks were not were not brought into the fold and I think you made an awfully good point about the inclusiveness of the current planning process and the respect and the reliance upon the landowners for their expertise and their knowledge of the land and their knowledge of the road systems and the bearing capacity of the soils and what equipment you can put where and where you can build a line and where you can't you also have to understand the viewpoint of the landowners we look at a forest we see an ecosystem we see trees we look at a forest they see hundred dollar bills and you don't like to see those going up in smoke so there's a tendency to fight for every acre if you're a landowner we're in our case there's sometimes a tendency to back off a little bit and fire it out one issue is this issue of plans yesterday we heard an awful lot about planning and putting together the plans etc and I think that I mentioned to you on Monday organizations that are very highly reliable spend a lot of time on plans they try to plan for every kind of contingency they develop protocols they do scenario planning they develop policies because they want to preempt things going wrong but by definition plans can't manage the unexpected plans don't plan for unexpected events and so there are two kinds of issues that I want to that I want to make with that first of all the issue is that you know plans can't handle what they don't expect and it really does influence mindfulness in this kind of way plans embody certain expectations about how the world is going to unfold and we have a tendency to look for information that confirms what we think is going to happen many organizational situations and many of the situations that you all face when you're in the field on an incident etc those situations are ambiguous and we have a tendency with our minds to fill in the gaps and to see what we want to see so plans can sometimes lead us to miss little small signals that things are developing are not going the way that we thought they were so that's one point about plans is that it's not to suggest that you don't do it plans of course are very important but one thing is that they can make us more mind less the other point is and actually I guess I've got three points the second point is that ordinary organizations oftentimes do not go back to their plans their existing protocols their standard operating procedures and incorporate new learnings high reliability organizations spend a lot of time revamping plans and protocols and standard operating procedures maybe that's normal for you all too in your units but a lot of organizations don't do that they have plans that have been around for years and they don't seem to update them third point we're not so much concerned with plans we're more concerned with the planning process we've been talking about process and this idea that this is a process of practices and procedures policies or principles that have to be continually enacted over and over some organizations do mindful planning other organizations do mindless planning mindless planning would be just having a checklist and going down and saying yeah we got that without doing a very rich discussion or a planning process that takes into account a lot of different kinds of views a lot of different stakeholders yesterday we heard Fred Wetzel talking about and we heard the people at the last part of the day as well talking about the planning process involving many different stakeholders in that process trying to figure out what could possibly go wrong there was a richness to that process that really gave them a sense of these are the kinds of things that could come up there were lots of there was a lot of input into that plan if you've got an inflexible a hierarchical kind of planning process it may lead to more mindlessness not mindfulness you have meetings all over the place everybody's been talking about gee I don't have any time to do anything I've got all these meetings okay what questions are frequently asked in those meetings what questions never get asked why not ask a different kind of question why not shift around the order which you go through some of the topics in a meeting so that some of those things are brought to the top ask yourself in your own unit what things that come up in a meeting get followed up what things are forgotten why not change that in some way what's referred to in the public statements by your group what are the themes that show up in the speeches can you work on those where do you spend your time haul out your calendar during the break look at it see where you're spending see if you can't adjust what it is that you're spending more time on and less time on is a signal to others of what strikes you as important what's important enough to call a meeting you're going to start calling meetings around a new issue now that's something that you can have some control over what kind of things get on the agenda what's on the first their first thing on the agenda what's last on the agenda there was the comment at the end that only three things came up and I hear it over and over again with incident management teams no one got killed we only had one slight injury and there was one other small thing that was the result of an after action review and it kind of led me to wonder well how rich are these after action review experiences sounds like they are very rich but there's this tendency I think to use as a metric for success did we kill anybody did everybody get home healthy and if we did that then we were totally successful and it kind of goes to this HRO idea of that we don't want to get into of saying we've got this lit we've got this done we don't need to keep looking at ourselves and thinking about how can we get better and better the AR process is accepted by leadership and they actually have introduced it into the IRPG and said that if not explicitly by having it there that they want us to use this process to identify our weaknesses and build on our strengths so there is a process in place already and it should give us then as a culture the opportunity to admit vulnerability to admit that we've got some things that we're working on so if we use that process they've already okayed that and given us permission to continually improve and say we're not perfect we didn't really talk about the first principle and that's preoccupation with failure and I see that even in this room we kind of fell into the trap of only focusing on everything they're doing right and I know people don't want to be critical because they're doing so much right but if we don't do that and I've only learned this from going through this workshop before and being involved in a very large escape and so I have learned for myself to be more preoccupied with failure and until you go through a big failure that you didn't see coming that you should have anticipated it's hard to look at things that way and I get accused of being a pessimist and I've been through it just kind of along what Dave said part of the AAR process is doing that near misses sometimes we used to laugh them off, whoa that was fun boy that was a blast instead of saying why did we almost lose it what saved our bacon what are we going to do next time after the morning HRO observations and dialogue workshop participants divided into their small facilitated discussion groups to answer six high reliability organizing questions the first two questions focused on the workshop's high reliability organizing theme remembering what we have learned from the case study experience what aspect of high reliability organizing already exist in our home organization and how might we do more of these HRO related practices or build upon them a summary of the insightful discussion findings that evolved from these questions have been published in the wildlandfire lessons learn centers written report that documents the entire workshop adopting the high reliability organizing principles into the wildlandfire organization is no easy task we are to successfully meet the wildlandfire management and hazardous fuel challenges that face us we must continue to improve our skills in managing the unexpected here at the second managing the unexpected national workshop to better explore the terrain of high reliability organizing participants journeyed out into the oki finoki swamp and now because of this facilitated voyage into the unexpected as these people return to their day to day wildlandfire organization operations they have a new enhanced awareness yes they are more mindful of the alligators that await them within their own work environment