20/20 Foresite
You know the old adage about how there are only two things certain in life — death and taxes? If you're a wildland firefighter, add one more to the list. As our country's enormous ecological restoration task continues to confront land managers across millions of public and private acres, there are now three certainties in life:
Death, taxes and hazardous fuels.
Unfortunately, it's nothing to joke about. There's absolutely no question that to reduce the threat of catastrophic fire and to restore ecosystem health across this country's forests and rangelands, hazardous fuel reduction and vegetation management activities are vital. Just look outside your window. We're decades, if not eons, behind the power curve.
On a national scale there are two proven methods for addressing this burgeoning fuels crisis: prescribed fire and fire use. Each year the implementation of these treatments increases dramatically, and that's not about to change anytime soon. However, prescribed fire has killed firefighters. It has escaped perimeters and threatened human life, completely toasted hundreds of homes, and cost billions in both losses and subsequent suppression expenditures.
So what are our land management agencies doing to ensure that, strategically and operationally on all levels, their personnel are prepared for this brave new world of ambitious prescribed-fire and fire-use treatments?
Take a bow, Wildland Fire Lessons Learned Center. This Tucson-based interagency-funded wildland fire nucleus provides a centralized knowledge and learning base for the country's extensive community of wildland fire organizations. Launched in 2002, the center's goal is “to help the wildland fire community become a true learning organization by developing a learning culture that works safer, smarter and is continuously improving,” says Center Manager Paula Nasiatka.
Nasiatka and Assistant Manager Dave Christenson are actively planning, coordinating and implementing, in a variety of effective ways, the center's wildland fire objectives of improving safe work performance, expanding organizational learning, sharing knowledge and promoting organizational change. The center's “Managing the Unexpected — High-Reliability Organizing” workshops have proved to be a significant forward step in actively addressing these critical objectives. (See sidebar on page 16.)
For example, a four-day workshop on prescribed fire and fire-use operations held in Santa Fe, N.M., focused on a staff ride field visit to the nearby site of the Cerro Grande Fire, the May 2000 prescribed burn that escaped and eventually rampaged into Los Alamos and its surrounding communities.
Revisiting this prescribed fire event with the people who had planned and implemented the burn allowed for hands-on insight into applying high-reliability organizing concepts. These insights included the kinds of problems and unexpected events associated with planning and implementing prescribed fire operations, along with how we can respond and learn from this ongoing process.
Following the pre-study of the event and the onsite field visit, the staff ride's integration phase identified lessons learned. This open-ended, no-holds-barred discourse was held the morning after the all-day Cerro Grande staff ride. Workshop participants expressed a variety of observations and insights. The following are direct quotes from staff ride participants during the integration phase discussion. They voiced their thoughts, lessons learned and suggestions for the future.
“It seems like our investigation reports like to play the blame game. Our bureaucracies like to do that. Maybe starting today, through the Wildland Fire Lessons Learned Center and this workshop's concepts, we can begin to look at these events as disasters.
“In essence, that's what Cerro Grande was. It was a disaster for many people both directly and indirectly involved. It was a disaster for the agency. And it was definitely a disaster for these folks who came back to share with us this week.
“After Cerro Grande I think we went immediately to: Who did what wrong? We didn't act like a true high-reliability organization that would say, ‘Let's really have a fundamental desire to look at what structures and processes we need to examine to avoid this type of disaster in the future.
“I think we're on the right track, we're moving forward in the right direction. It comes down to what Karl Weick and Kathleen Sutcliffe talked about the first day. It's going to take repetition to develop a new organization behavioral action. We need to practice this over and over again. When the next crisis or disaster occurs, we don't want to go back to our previous institutional behavioral action. That's our challenge.”
“Even though I was on the Type-1 Interagency Management Team assigned to the Cerro Grande Fire, I learned a whole lot more about this fire yesterday on the staff ride. What I now know about this prescribed fire … and what the investigation reports say are two different things. We need to find a way to set the record straight.”
“I think we all realize the difference between the investigation reports and some of the data that we heard yesterday. It's been my experience on other staff rides, after we've gone out on the ground and really assessed what occurred, that we need to be very careful about how we formulate our perceptions and opinions based on these reports.”
“I firmly believe that the whole investigation process needs to be revisited. We all know mistakes are going to happen, hopefully not on this scale. But I'd like to think that when we conduct these post-event processes — these investigations and reviews — that we protect our employees and not abandon them.”
“When I listen to some of the data that went into making those decisions regarding that prescribed fire, it reinforces the very cynical outlook I have about us, about our profession — specifically, how inadequately we prepare ourselves to make our very complex decisions. We are continually using models or modeling concepts that are developed for wildfire suppression and trying to adapt them into a prescribed-fire setting, particularly with the use of the Haines Index.”
“What I saw yesterday was a difficulty in analyzing risk. Everything we do is how we look at risk and how much risk we are willing to take. But it is very difficult for us to get a true handle on what the risks are that we are taking. Why are we so willing to take these risks, other than it's just our job to do this? What rewards or what benefits are we getting for going out there and taking that risk?
“In terms of the [Cerro Grande] prescribed fire, I would have taken that risk, too. Yes, I am a risk-taker, as most of the people in this room probably are. But why are we taking this risk? We don't reward people for taking these risks. What rewards do we get? Our agencies certainly don't reward us for taking this risk. They only come out and look when there has been a problem. They don't come out and look at the good successes. How many workshops do we have in which we get together to look at what we have accomplished? None. We only look at problems. We need to start rewarding people for taking risks, even when circumstances go bad.”
“One thing that struck me yesterday that's been gnawing on me for several years is that once we get beyond about two days from our weather forecasts, we're really susceptible to unknowns. It's been my experience that I can trust the weather forecast for about 48 hours. Beyond that it's a crapshoot. As we start to go more and more toward landscape-level and multi-day burns, we're really headed into a gray area. It really makes me wonder where we're going in the future and how we're going to accomplish our target goals.”
“Sometimes with the situations we are dealt, due to the shape of the landscape and ecosystems — how we have so much Condition Class III lands that we're trying to do something with — the tendency for a lot of agencies … is to go out there and fix everything right away. I believe there is also a political emphasis to do this, and I don't think that's right. That's not what we should be doing.
We have all these areas that are supposed to burn, for instance, once every five to 10 years that haven't had any fire for 100 years. So we try to go out and meet all of our objectives and return it back to that five- or 10-year burn cycle all in one burn. In doing so, I don't think that we're doing the ecosystem right. And I don't know if we're doing our personnel right by asking them to do that. Trying to meet all our objectives all at once might be something we need to reconsider.”
“I was reminded again yesterday of the inadequacy of the national prescribed-fire curriculum. It needs to be adjusted and overhauled. It doesn't address landscape-scale burning at all. There is no book on landscape-scale prescribed burning. Perhaps we should all think about that today in our future efforts to put a better prescribed-fire program together to help the people that will be coming up behind us. It's our job to grow the best fire management programs that we possibly can.”
“I'm a local government fire chief. We do micro-burning, on a very small scale. After the staff ride, what struck me was that on our burns we staff with three or four times the people you do. From a risk management point of view, you need to take a look at how you are staffing and your contingencies. Are they in place to do the job? I don't know how you guys do this. It seems like you really need to determine: Do you truly have enough folks on the ground to do the right job?”
“What struck me really hard yesterday — and it's still a huge problem for us — is the concept of contingency. L.A. County can call on first alarm and get 141 people. On the [Cerro Grande] prescribed fire we were only asking for one hand crew, and we couldn't get it. Where are our contingencies and what are they going to be in the future? I'm really concerned about how we are going to play this game out with the dispatch organization.”
“One of the presenters yesterday said how they were thankful that they had an opportunity to tell their side of this event. Certainly, considering all the liability that is surrounding these folks and their agencies, it's understandable how they might not want to say a lot. But it's important; it's important to them, and it's important to us as professionals to hear their side, especially presented in a way in which these people can feel safe doing this.”
“It's important to remember that there was more that transpired at Cerro Grande than this prescribed fire. While we focused on the prescribed fire on this staff ride, we really have multiple stories to tell — and to examine. The Type-3 and the subsequent Type-1 wildland fire event also led to the end result that was so tragic. It wasn't just solely that prescribed burn.”
Paul Keller, managing editor of Fire Management Today, served on the Zigzag Interagency Hot Shot Crew from 1985-90.
At the week-long Managing the Unexpected Workshop in Santa Fe, N.M., Drs. Karl Weick and Kathleen Sutcliffe tackled a variety of concepts, tools and skills.
Coauthors of Managing the Unexpected — Assuring High Performance in an Age of Complexity, Weick and Sutcliffe are nationally recognized experts on organizations, strategies and management. They are heralded for helping to develop the concept of high-reliability organizing. Wildland firefighters are one of groups with which Weick and Sutcliffe are studying and working.
Weick is the Rensis Likert Distinguished University Professor of organizational behavior and psychology at the University of Michigan Business School. His research interests include high-reliability performance, collective sense-making under pressure, and handoffs in extreme events.
Sutcliffe is an associate professor of organizational behavior and human resource management at the University of Michigan Business School. Her research is devoted to high-reliability organizing and understanding the fundamental mechanisms of organizational adaptation, reliability and resilience.
“In our work we think about the idea that you can try to anticipate as much as you can,” says Sutcliffe. “But as you implement prescribed fire, you certainly are not going to be able to anticipate everything. Whether there is a certain risk that you are willing to live with is one thing. But there is also really focusing on that part of trying to contain or to act on the surprises that do come up. That's where I would be spending most of my time.…”
Weick and Sutcliffe outlined several objectives for the Managing the Unexpected Workshop participants, who represented various local, state and federal agencies from all levels of their organizations. All of the participants are directly involved in planning, implementing and learning from prescribed fire and fire-use operations. They were charged to:
- Broaden options for dealing with surprising situations.
- Provide ideas that can help rethink the consequences of current practices.
- Provide organizing practices that can increase the awareness of small mistakes that can grow into large crises.
- Help build a customized view of how to coordinate activities to produce more reliable outcomes.
“Failure to move toward this kind of structure — one that is constantly tracking all of these things — magnifies the damage that can be done by unexpected events, and will impair reliable performance,” says Weick.
He emphasized that unless you create a “mindful” infrastructure that is continually tracking these five HRO principles, expectations can get you into trouble.
“The often unspoken emphasis here is that moving toward this kind of a mindful infrastructure is far harder than it looks,” cautions Weick. “It means flying in the face of paying attention to your successes, simplification, strategy, doing planning and paying attention to your superiors.”
Weick also outlined the five key principles that buttress and propel high-reliability organizing:
- Preoccupation with failure
HROs are preoccupied with all failures, especially small ones. Small things that go wrong are often early warning signals of deepening trouble and give insight into the health of the whole system. However, people have a tendency to ignore or overlook their failures, which suggest they aren't competent, and focus on their successes.
- Reluctance to simplify
HROs restrain their temptation to simplify through diverse checks and balances, adversarial reviews, and the cultivation of multiple perspectives.
- Sensitivity to operations
HROs make strong responses to weak signals. Everyone values organizing to maintain situational awareness.
- Commitment to resilience
HROs pay close attention to their capability to improvise and act, without knowing in advance what will happen.
- Deference to expertise
HROs shift decisions away from formal authority toward expertise and experience. Decision-making migrates to experts at all levels of the hierarchy during high tempo times.
A summary of the workshop, Managing the Unexpected in Prescribed Fire and Fire-Use Operations — A Workshop on the High-Reliability Organization, is available through the Wildland Fire Lessons Learned Center. A video/DVD production that captures the entire week, including the Cerro Grande Staff Ride, is also available through the center at www.wildfirelessons.net.
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