company logo high reliability organizing implementation in fire crews
TRANSCRIPT
Company
LOGO High Reliability Organizing
Implementation in Fire Crews
Agenda
1. Use Fire Analysis to go to HRO 1. Use Fire Analysis to go to HRO
2. Five HRO Processes 2. Five HRO Processes
3. Requisite Culture for Success 3. Requisite Culture for Success
Fire Management
Wildland Fire an HRO?
• “High Reliability Organizations– Nuclear power plants– Aircraft carriers– Wildland firefighting crews
Maybe yours, but not mine!
• How about our prescribed fire programs?Common “surprises” from 28 Escapes and 2 Near Misses 1996-2004 LLC Report
Mindfulness
•To be mindful
•Mindful updating
The past settles its accounts
“…the ability to deal with a crisis situation is largely dependent on the structures that have been developed before chaos arrives. The event can in some ways be considered as an abrupt and brutal audit: at a moment’s notice, everything that was left unprepared becomes a complex problem, and every weakness comes rushing to the forefront.”
Preventing Chaos in a Crisis, Lagadec, p. 54
1. Preoccupation with Failure
Thinking about our own fire dispatch unit, can we honestly say:
• We regard near misses as a kind of failure that reveals potential danger rather than as evidence of our success and ability to avoid danger
• We treat near misses and errors as information about the health of our system and try to learn from them
Triangle of Probability
1
30
300
Triangle of Probability
20
600
6000
2. Reluctance to Simplify
Thinking about our fire crew, can we say:
• People around here take nothing for granted
• People are encouraged to express different points of view
3. Sensitivity to Operations
• During an average day, people come into enough contact with each other to build a clear picture of the situation.
• People are familiar with operations beyond one’s own job.
4. Commitment to Resilience
• There is a concern with building people’s competence and response repertoires.
• People have a number of informal contacts that they sometimes use to solve problems.
5. Deference to Expertise
• If something out of the ordinary happens, people know who has the expertise to respond
• People in this organization value expertise and experience over hierarchical rank
Toward a “Mindful Culture”
• A healthy safety culture consciously creates mindfulness.
• Strive for an “informed culture”– a culture that creates and sustains intelligent wariness. – James Reason
• Informed cultures result from four co-existing subcultures:
Four Subcultures
–Reporting culture
–Just culture
–Flexible culture
–Learning culture
Dependency Diagram
First Second Third Fourth
JustCulture
TrustClarity
ReportingCulture
ReportingRelationships
FlexibleCulture
Adaptable
LearningCulture
Toward a Mindful Culture
First Second Third Fourth
JustCulture
TrustClarity
ReportingCulture
ReportingRelationships
FlexibleCulture
Adaptable
LearningCulture
Pay Attention Differently
• You STOP concentrating on some things.
• You START concentrating on other things.
• To Be MindfulIs to “See more Clearly” Not to Think Harder and Longer
“See more clearly”
• See where your model didn’t work, or see indicators you missed that signaled expectations weren’t being filled (failure)
• Strip away labels, stereotypes that conceal differences among details (simplification)
• Focus on what is happening here and now (operations)
• See new uses for old resources through improvisation and making do (resilience)
• Discover people who understand a situation better than you do and defer to them (expertise)
Plans and Their Drawbacks
• Plans influence what people see
• Plans can limit our view of our capabilities
• Plans focus attention on what we expect
Preoccupation with Failures
All Failures
Especially The Small Ones
Learning by Failure – Hard
Learning moments are short-lived
Don’t wait
Do it the right way
James Reason, 2006
The Person Model
The Legal Model
The System Model
Satisfying with “Justice Fruit”
Upward and Outward
A Balanced Approach?
Use A Balanced Approach?
• Person Approach?
• Legal Approach?
• System Approach?
• Learning Approach
• Learning requires some preconditions:
psychological safety
learning orientation
efficacy
Learning Ground Rules
2. Reluctance to Simplify
Our Expectations
3. Operations-Sensitive Leadership
• Encourage others to speak up
• Check for comprehension
• “Over Learn” new routines
4. Commitment to Resilience
• A combination:–Keeping errors small and
–Improvising workarounds that keep the system functioning
• Build dynamic thinking skills
• Develop creativity
• Value variability
5. Defer to Expertise
• HROs shift decisions toward expertise and experience.
Sensemaking vs Decisionmaking
• “If I make a decision it is a possession; I take pride in it; I tend to defend it and not to listen to those who question it.
• If I make sense, then this is more dynamic and I listen and I can change it.
• A decision is something you polish. Sensemaking is a direction for the next period.”
--Paul Gleason
STICC – Explain Yourself
• Situation
• Task
• Intent
• Concern
• Calibrate
Continually Ask Yourself
• Scanning questions:– Can I see weak signals of failure and make
sense of them?– How many different slides do I have that
apply to this situation?– Am I aware of the unfolding situation? – Do I have the skills to make do? – Who knows how to do what?
Five Continuous Processes
deference
preoccupationreluctance
sensitivity
commitment
Manage the Unexpected
Mindful Updating
Five Processes
1. Preoccupation with failure 1. Preoccupation with failure
2. Reluctance to simplify 2. Reluctance to simplify
3. Sensitivity to operations 3. Sensitivity to operations
4. Commitment to resilience 4. Commitment to resilience
5. Deference to expertise 5. Deference to expertise
Cultural Progression to HRO
JustJust ReportingReporting FlexibleFlexible LearningLearning
Mindfulness Defined
• “By mindfulness we mean the combination of–Ongoing scrutiny of existing expectations,
–Continuous refinement and differentiation of expectations based on newer experiences,–Willingness and capability to invent new expectations that make sense of unprecedented events,–A more nuanced appreciation of context and ways to deal with it,–And identification of new dimensions of context that improve foresight and current functioning.”
Where we are going
Information to Knowledge
Informed Culture
Timely AvailableCandid Disseminated
Learning Culture
Agenda
1. Use Fire Analysis to go to HRO 1. Use Fire Analysis to go to HRO
2. Five HRO Processes 2. Five HRO Processes
3. Requisite Culture for Success 3. Requisite Culture for Success
Commitment – Pick Two
1. Preoccupation with failure 1. Preoccupation with failure
2. Reluctance to simplify 2. Reluctance to simplify
3. Sensitivity to operations 3. Sensitivity to operations
4. Commitment to resilience 4. Commitment to resilience
5. Deference to expertise 5. Deference to expertise
HRO Support at LLCwww.wildfirelessons.net
HRO Support at MFCwww.myfirecommunity.net
Questions? Contact Us
• Paula Nasiatka, LLC Manager– (520) 799-8760, [email protected]
• David Christenson, LLC Asst. Mgr.– (520) 799-8761, [email protected]
• Brenna MacDowell, LLC Editorial Asst.– (520) 799-8763, [email protected]