Wildland Fire Lessons Learned Center

High Reliability Organizing

A lesson is learned when we change our behavior.

Medical Response Stickers for your IRPG

Learning Highlights from the 4th International High Reliability Organizing Conference
Keynote Speaker: Karl Weick, PhD, Coauthor of the book Managing The Unexpected: Resilient Performance in an Age of Uncertainty
Featured Wildland Fire Speaker: Tom Harbour, MS, Director of U.S. Forest Service Fire & Aviation Management

High Performance and High Reliability – Building Performance Based Organizations

(Posted 3/9/2010) This video highlights a few interviews from the 3^rd International Conference of High Reliability Researchers and Practitioners, held at the University of New Orleans, January 9-10, 2010. Interviewees discuss approaches to how we can best learn HRO practices from other industries and organizations. Proceedings from the conference will begin to appear here soon.

Improving Reliability with "System Think"

by: Christopher Hart

A presentation from the 3^rd International Conference of High Reliability Researchers and Practitioners, held at the University of New Orleans, January 9-10, 2010.

Mindfulness - Where and How to Start?
by: Shirine Moerkerken

A presentation from the 3^rd International Conference of High Reliability Researchers and Practitioners, held at the University of New Orleans, January 9-10, 2010.

HRO Research
NEW!
The France-USA HRO Project - "Enhancing Reliability in Incident Management" Working Paper (1.3 MB pdf posted 7/15/2010) The close-out presentation to the US of the France-USA High Reliability Organizing Project to Enhance Reliability in Incident Management was conducted on July 1, 2010 in Marseille, France. This presentation was prepared and presented by Renaud Vidal, Research Engineer, Centre d’Etude et de Recherche en Gestion Aix Marseille (CERGAM).

France/USA HRO Project Close Out Meeting Webinar (Posted 07072010) The close-out presentation to the US of the France-USA High Reliability Organizing Project to Enhance Reliability in Incident Management was conducted on July 1, 2010 in Marseille, France and recorded by GoToWebinar. An earlier version was given to the French team at the end of 2009.

France-USA High Reliability Organizing in Incident Management Teams Project
Just like NYPD detective "Popeye" Doyle, who traveled to Marseilles in the 1970s hit movie “the French Connection” so too, did a Forest Service NIMO team this past December. Only it wasn’t for crime busting this time. It was a landmark match-up between two French and American Incident Management Teams to capture what makes these teams so successful in complex, rapidly changing, stressful situations. It is hypothesized that they exhibit many of the behaviors that directly align with high reliability organizing (HRO) concepts and principles.

HRO Audits
From the 2007 Edition of "Managing the Unexpected" Nine High Reliability Organizing Assessments you can use to audit your own unit or organization and advice from the authors on How To Use The HRO Audits and Results.

1. A Starting Point for Assessing Your Firm's Mindfulness

2. Assessing Your Firm's Vulnerability to Mindlessness

3. Assessing Where Mindfulness Is Most Required

4. Assessing Your Firm's Preoccupation With Failure

5. Assessing Your Firm's Reluctance To Simplify

6. Assessing Your Firm's Sensitivity To Operations

7. Assessing Your Firm's Commitment To Resilience

8. Assessing Your Firm's Deference To Expertise

9. The Mindfulness Organizing Scale

HRO Video

HRO for Wildland Firefighters An Introductory Video

(19MB wmv video file posted 9/11/08) Introductory video - Creating a better mindset for wildland firefighter safety and survival.

HRO Stories Series
NEW!

L-580 Gettysburg Staff Ride

Can wildland fire leadership or High Reliability Organizing (HRO) be taught—or can it only be learned?

[886 kb pdf]

[Posted 6/7/11]

HRO Story: Acting in the HRO Moment - Let's give it a try ( 157KB pdf posted 10/6/2009) In the wildland fire community we have, as every organization does, developed a style of work. It is our corporate culture: what analysts say boils down to "the way we do things around here." Karl Weick and Kathleen Sutcliffe say in Managing the Unexpected, that corporate culture is what holds our groups together and sets prevailing tones. "An organizational culture emerges from a set of expectations that matter to people." What happens in your organization when someone introduces a new idea? Do you notice a willingness to try something new? Or, are early adopters scarce in your group?

HRO Story: Using Sensitivity to Operations to See the Work Clearly (221KB pdf posted 8/20/2009)
Psychologists say, when individuals are involved in a situation, they often lose sight of the situation they are in. How do fire managers and other leaders who regularly lead people into intense, rapidly changing situations remain cognizant of the reality of the situations they are in? Are they, too, in danger of losing sight of the “real work?”

HRO Story: Mindfulness - Are we managing our expectations? (638KB PDF posted 7/2/2009) A fourth HRO Story from LLC Staff Writer Jonetta T. Holt:
Incident management teams bring order to chaos. We believe order is a good thing. But when does order create blindspots for us?

HRO Story: Creating Resilence on a Fire Assignment

Gates Park Fire Progression Map (Click to see larger image)

(1005KB pdf posted 5/12/2009) A third HRO Story from LLC Staff Writer Jonetta T. Holt
"Managers who lead crews and teams into high risk environments want to believe the group they are leading is skilled, capable, strong… resilient, even. Do we know what we mean when we are talking about having resilience or behaving resiliently?" Print Quality Gates Park Fire Progression Map (2 MB)

Morning Briefings Reinforce Deference to Expertise

A second HRO Story (322KB pdf posted 9/14/2008) An HRO Story - "Managers who work in high risk environments, such as wildland fire, are often tasked with “briefing” crew leaders about the potential hazards they and their crews face and instruct them on what actions to take when those hazards become realities."

Tracking and Responding to Small Errors in High Risk - An HRO Story This is the first HRO Story of the series (312KB pdf posted 7/25/2008) Those who work in high risk environments know they must pay close attention to tracking and responding to small system failures before they become big problems, even deadly catastrophes. But what does tracking on the health of the system mean? Often the act of recognizing that something is wrong, that a small failure has occurred, without being able to pinpoint the actual cause is confusing and creates hesitation.

HRO Case Studies Series

HRO Case Study: HRO Implementation on the Shoshone National Forest (535KB pdf posted 3/17/2009)
Third in a series, the HRO Case Study Series looks at HRO in the Wildland Fire Setting - "Personnel on the Shoshone National Forest mark 2006 as a bad year, but one that also demonstrated the Forest’s commitment to resilience. On April 10th of that year, the Homestead Park II prescribed burn escaped control under adverse weather conditions, spreading onto private property and burning four cabins."

Case Study: Incident Management Teams as Vehicles of HRO Implementation (779KB pdf posted 11/4/2008) High Reliability Organizing (HRO) related training was conducted at the Southwest Incident Management Team's 2008 Annual Meeting. During the year several IMTs continued to work with members of the instructor cadre. This document begins to illuminate the important role that IMTs can play in increasing the awareness of HRO principles already at some levels in wildland fire management that we can build upon.

High Reliability Organizing Implementation at Sequoia & Kings Canyon National Parks - An HRO Case Study (833 Kb PDF posted 8/11/2008) SEKI created an institutional structure enabling bottom-up empowerment, effectively institutionalizing self-empowerment in their safety program. Park personnel began their efforts by consciously actualizing one HRO principle; preoccupation with failure.

HRO and Information Collection Team Reports

Prescribed Fire Escapes and Near Miss Lessons Learned (610KB pdf posted 10/31/2008) In many of the prescribed fire escapes examined during this Information Collection Team effort, frequent problems stemmed from a lack of adequate communication and coordination between members of the burn team—in both the planning and implementation phases. This is a Lessons Learned Center Information Collection Team analysis; with a series of key findings and sand table "prompts" using the principles of High Reliability Organizing.

HRO Workshop Series

HRO Workshop in Vero Beach, FL October 2009 Announcement (238KB doc posted 5/6/2009)
The Wildland Fire Lessons Learned Center, The Nature Conservancy, Florida Park Service, and the Central Florida Prescribed Fire Council sponsored a workshop on High Reliability Organizing (HRO) in Central Florida, October 20-22, 2009. Details about this session are included in this document.

HRO Workshop Announcement October 2008 - Albany, NY The Wildland Fire Lessons Learned Center, The Nature Conservancy and the Northeast Region of the National Park Service sponsored a workshop on Managing the Unexpected in Wildland Fire Operations on October 7-9,2008.

Managing the Unexpected in Prescribed Fire and Fire Use Operations: A Workshop on the High Reliability Organization (2.5 MB PDF posted 100504) Keller, Paul (tech. ed.). 2004. RMRS-GTR-137. Fort Collins, CO: U.S. Department of Agriculture, Forest Service, Rocky Mountain Researc h Station. 73 p. publication on the Santa Fe workshop held in May 2004.

Managing the Unexpected in Prescribed Fire and Wildland Fire Use Operations: A Second Workshop on High Reliability Organizing Final Report Part 1, 2, 3, 4, 5 (posted 062206) Keller, Paul (tech. ed.). 2006, PowerPoint Presentations: Karl Weick and Kathleen Sutcliffe HRO Complete Presentation (70 slides), HRO Short Version (29 slides), and the introductory presentation by Scott Snook titled "A Different Way of Thinking About Leading and Change" Workshop was held in Jacksonville, Florida in February 2005.

Managing the Unexpected in Wildland Fire Operations: A Third Workshop on High Reliability Organizing (667 KB PDF posted 090106) This overview publication by Paul Keller highlights the key points from the Missoula, Montana workshop in May 2006. The workshop evolved from a nationally organized effort aimed at helping fire management practitioners successfully implement high-risk fire operations—wildland fire use, prescribed fire and wildfire suppression—safely and effectively. The central objective was to help participants be able to apply a High Reliability Organizing (HRO) framework to their work at their home units in a variety of fire management operations. A Staff Ride to the I-90 Fire Shelter Deployments Site was part of the workshop.

HRO Papers and Articles Series

NEW! Overcoming dysfunctional momentum: Organizational safety as a social achievement (140KB pdf posted 8/18/2010)
by: Michelle A Barton and Kathleen Sutcliffe
Research on organizational safety and reliability largely has emphasized system-level structures and processes neglecting the more micro-level, social processes necessary to enact organizational safety. In this qualitative study we remedy this gap by exploring these processes in the context of wildland fire management. In particular, using interview data gathered from 28 individuals involved in wildland firefighting, we explore the validity of the idea that a deterrent to organizational safety is an inability to redirect ongoing actions once they are underway.

NEW! HRO alone is not the "Silver Bullet!" Leading Connection Development and Knowledge Flow to Increase HRO Implementation Effectiveness is a paper delivered at the 3rd International High Reliability Organizing Workshop in New Orleans, LA by David Christenson, Acting Center Manager of the U.S. Wildland Fire Lessons Learned Center. (61 Kb PDF posted 2/24/2010)
An excerpt from this paper:
"Many units in high risk industries will use the audits provided in the Managing the Unexpected books to discover where they are at....Some units are able to move forward but others get stuck at this point because: Fundamental to success in HRO implementation are the connection of people and the trust necessary for optimal knowledge flow."

HRO Behaviors - Getting Better Balanced By Producing Results ( 101KB pdf posted 8/17/2009)
Getting Better Balanced by Producing Results on the Real Problems "Getting better is based upon the principles of continuous improvement, continuous learning, and continuous change. The Japanese call it kaizen and, because it builds trust, it becomes a powerful relationship building tool. When people see you as a learning, growing, renewing individual or organization they develop confidence in your ability to succeed in rapidly changing environments..."

HRO Behaviors - Straight Talk Balanced By Demonstrating Mutual Respect (59KB pdf posted 8/17/2009)
Straight Talk Balanced by Demonstrating Mutual Respect "Several team HRO behaviors depend upon successfully creating an environment where honesty and candor is expected from individuals. Talking straight is based upon the principles of honesty and integrity. You want to leave the right impression by communicating clearly enough to assure you are not misunderstood..."

Incident Management Team’s HRO Behaviors (29KB doc posted 3/10/2009)
This information has been revised for incident management teams by the Wildland Fire Lessons Learned Center. It was originally produced on pages 62-63, and 80-81 of the book Managing the Unexpected: Resilient Performance in an Age of Uncertainty, a second and revised edition by Karl E. Weick and Kathleen M. Sutcliffe, published by in 2007 by Jossey-Bass of Wiley and Sons.

Fire Management Today - Managing the Unexpected (869KB pdf posted 7/25/2008) This issue of Fire Management Today, number 2 of Volume 68 is focused on Managing the Unexpeted and HRO.

The First Basic Teaching Guide for Introducing High Reliability Organizing to the Wildland Fire Community: From the Field to Line Officers
This special guide for teaching and facilitating High Reliability Organizing (HRO) reflects the presentations that were made at the three-day May 2007 Facilitating HRO in Wildland Fire workshop. By using and following this guide, the HRO teacher will understand the fundamentals of HRO and will be better prepared to facilitate these principles to others. Author Paul Keller, March 2008.

HRO Briefing Paper

This one page paper was written by Dave Christenson to give a quick overview of HRO.

Build a Healthy Safety Culture Using Organizational Learning and High Reliability Organizing (323 KB PDF posted 12082007) Written by David Christenson
A paper presented at the Wildfire2007 international conference of wildland firefighters in Seville, Spain, May 2007. This paper introduces people to successful techniques in the integration of organizational learning and high reliability organizing that can lead to building and sustaining a healthy safety culture. Presentation with speaker's notes.

Where to Next with High Reliability Organizing (59 KB, posted 090506) This white paper was prepared after a meeting at the LLC in Tucson in July 2006. Drafts of this paper were shared with interested members of the HRO Community of Practice. Dr. Weick and Dr. Sutcliffe have also offered their comments. The paper has been revised to reflect this feedback. The meeting’s objectives were: 1) Should we continue to use the national Managing the Unexpected workshops as the primary method of “teaching” HRO? 2) Is it time to change and/or modify approaches to teaching HRO? and 3) What new approaches to applying HRO to fire management operations are most pertinent at this time?

Columbia Accident Investigation Board's Report (Link posted 060304) Karl Weick recommended that the workshop group consider reading this specific report. CAIB devotes a whole chapter, some 50+ pages to "Decision Making at NASA." There is also a chapter on "The Accident's Organizational Causes." "In the Board's view, NASA's organizational culture and structure had as much to do with this accident as the External Tank foam."

HRO Presentations Series

Applied HRO Presentation (3.5 MB PPTX, Uploaded 3/21/2010) Delivered by HRO Mentors David Allen and Kristy Lund at the March 2010 S-520 Course as part of the HRO section at the National Advanced Fire & Resources Institute. This version includes speaker notes but not the short video originally inserted with slide #15.

HRO - High Reliability Organizing
(707KB ppt posted 2/4/2008)
High Reliability Organizing presentation with speaker notes in the downloadable version is a shortened HRO-focused version of the Building A Healthy Safety Culture Using Organizational Learning and High Reliability Organizing paper/presentation.

A High Reliability Organizing Presentation for Field Crews (14 Mb PPT posted 061108) provides many of the HRO fundamentals that crews, crew bosses and other fire units of all kinds will find applied and useful. Created by David Christenson, this half-hour training comes complete with presenter notes.

An Overview of Managing the Unexpected For Managers presentation (178 Kb PPT) provides an overview of HRO principles and their relationship to the writings of several other people involved with organizational risk management. Created by Dr. Jim Saveland, it is also organized so that the viewer can see how Managing The Unexpected using a mindful approach is very relevant to the world of the wildland firefighter.

Readings in Risk, Organizations, and Wildland Fire

Researchers from the University of Montana and the Rocky Mountain Research Station have published an annotated reading list of resources related to the human side of fire management, focused primarily on understanding organizational dynamics in wildland fire. The publication contains a very useful section on organizational learning and high reliability organizing.

Instructor Cadre on Implementing HRO

HRO Incident Organizer - Word Document

(171KB - 11/30/2006)

Created by Timothy Greer
This document is an incident organizer developed by an FBAN from New Brunswick, Canada. It was developed following Karl Weick's recommended communications structure in high reliability organizing.

Taking HRO Home - A Worksheet Exercise

(53 KB - 6/9/2006)

Created by Paula Seamon

"The purpose of this exercise is to help you think through the many options for taking HRO home and focus on a few first steps. At the conclusion, you will have a simple plan for two things: communicating the HRO concepts, and putting the principles into action within your target group."

Organizational Characteristics that Contribute to Success - Power Point Presentation

(880 KB - 5/18/06)

Organizational Characteristics that Contribute to Success - Word Document

(69 KB - 5/19/2006)

Created by Katie Knotek and Alan Watson

Organizational Characteristics that Contribute to Success in Engaging the Public to Accomplish Fuels Management at the Wilderness/Non-Wilderness Interface. "In the fall of 2003, the Rocky Mountain District of the Lewis and Clark National Forest initiated a multi-year, large-scale prescribed burn in the Scapegoat Wilderness. The objectives of this burn were to make the non-wilderness side of the wilderness boundary more defensible from wildfire and to establish conditions that will allow fire to play a more natural role within the wilderness in the future."

High Reliability Organizations: San Juan Interagency Hot Shot Crew - Power Point Presentation

(2190 KB - 06/02/06)

High Reliability Organizations: Presentation Paper - Word Document

(27 KB - 06/05/06)

Created by Shawna Legarza

This power point details five elements of HRO's and how the San Juan Interagency Hot Shot Crew integrated them into use.

Implementing HRO at the National Forest Level - Power Point Presentation

(1274 KB - 06/05/06)

Created by Brett Fay

"Implementing the HRO discipline can be a challenge...especially if it is described as the 'next best thing.' Instilling the practices may be more effective by the realization of positive outcomes..."

Organizing for High Reliability in Wildland Fire Management -Power Point Presentation
(544 KB - 06/05/06)

Created by Anne Black

"Where do we go from here?" A power point delving into how HRO can be implemented and used within wildland fire management.

The Lessons Learned Center is currently has been working with HRO pioneer Dr. Karlene Roberts, Professor in the Graduate School at University of California at Berkeley, Haas Organizational Behavior and Industrial Relations Group. Take a few moments to read her paper on how HRO Has a Prominent History.

Karlene Roberts is a lecturer and full professor at Haas School of Business, UC Berkeley,
a Research Psychologist at the Institute of Industrial Relations and is an Associate Director, at the Center for Catastrophic Risk Management. She has visiting appointments at: Graduate School of Management, University of California, Irvine and Hong Kong University of Science and Technology
Current Research and Interests: The design and management of organizations and systems of organizations in which errors can have catastrophic consequences. The results of this research have been applied to U.S. Navy aircraft carrier operations, the U.S. Coast Guard, The Society for Worldwide Interbank Financial Telecommunication (SWIFT), The Federal Aviation’s Air Traffic Control System, Gard Services, British Petroleum, NASA, and the medical industry. Currently working with incident management teams in the U.S. and France on an international project interested in improving reliability in the high risk environments of wildland fire.

The Center is also very fortunate to have a close working relationship with the coauthors of the highly acclaimed book Managing the Unexpected: Resilient Performance in an Age of Uncertainty. (revised edition, 2007)

Dr. Karl Weick, University of Michigan
Karl E. Weick is the Renis Likert Collegiate Professor of Organizational Behavior and Psychology and professor of psychology at the University of Michigan Business School. Dr. Weick's research interests include collective sensemaking under pressure, medical errors, handoffs in extreme events, high-reliability performance, improvisation and continuous change.

Kathleen Sutcliffe, University of Michigan Kathleen M. Sutcliffe is a Professor of Management Organizations at the University of Michigan Business School. Dr. Sutcliffe's research is devoted to understanding the fundamental mechanisms of organizational adaptation, reliability, and resilience. Her work focuses on processes associated with team and organizational resilience, high-reliability organizing, and investigation of the social and organizational underpinnings of medical mishaps, with the explicit goal of understanding how an organization's design contributes to its member's ability to successfully manage unexpected events

Disclaimer: Information is provided with the intent to share knowledge to improve safety, performance, efficiency and organizational learning throughout the entire wildland fire community. However, no warranties or guarantees are implied because much of the data provided is beyond the control of the Center. No endorsement of any company or product is given or implied.