750 likes | 756 Views
This publication explores accident prevention analysis (APA) and the Meadow Creek Fire APA process, providing insights into communication, organizational culture, and sensemaking in the wildland fire environment.
E N D
Communication in the Wildland Fire Environment With selected lessons from the Meadow Creek Fire APA Leadership and Organizational Development Conference: Building Our Future PNW Fire Operations Safety & Leadership Sunriver Resort ~ Bend, Oregon March 2011 Jennifer A. Ziegler, Ph.D. Valparaiso University Valparaiso Indiana http://blogs.valpo.edu/jziegler/publications
Accident Prevention Analysis (APA) • Meadow Creek Fire APA • The Story • APA Team Lessons Learned Analysis • “Collective Sensemaking” • Reflections on the APA Process
“APA” I. Accident prevention analysis
APA • Alternative prototype accident investigation (USDA FS) • Predicated on “Just culture” • Reporting culture Learning culture • Promise of no punitive action
APA, cont’d. • Emphasis on “the story” from the point of view of the participants • Including participant lessons learned • Analysis seeks to understand: • How did conditions, decisions, and actions make sense to the participants? • What can that tell us about our organization & culture? • What lessons can be gleaned for broader organizational learning?
July 2010 II. Meadow Creek Fire APA
Timeline • July 5: Accident • July 30: Discovery • Aug 3: Team convened • My role: SME Organizational Communication and Culture • September 28: Report completed
APA process • Objectives • The accident (June 20-July 5) • Follow-up reporting (July 5-August 2) • 35 Participants • 2 modules • Module 1 (injured ff) • Module 2 • 2 regions • Home unit for Module 1 • Host unit • Also home unit for Module 2
Key sections • The Story • Participant Lessons Learned • APA Team Lessons Learned Analysis
Key sections • The Story • The Accident • Follow up Reporting • The Accident
Web cam Lookout Accident Site Fire Origin RAWS Private
Key sections • The Story • The Accident • Follow up Reporting • Follow up Reporting
Key sections • The Story • Participant Lessons Learned • APA Team Lessons Learned Analysis
Key sections • The Story • Participant Lessons Learned • APA Team Lessons Learned Analysis
Key sections • The Story • Participant Lessons Learned • APA Team Lessons Learned Analysis • Risk Management • Reporting • Sensemaking • Individual • Collective • Group and Local • Institutional
Sensemaking Lessons • Collective sensemaking is a truly social process. • Begins with the individual • Requires the input of many people • Employees use language to manage risks that emerge from the organizational environment. • Perceptions of leaders can influence upward and lateral voice. • “Life happens.” And can challenge expectations for clear and timely communication.
A Truly Social Process 1. Collective sensemaking
Why sensemaking? • “where employees made mistakes” • “what should have been done” • “illuminate why employees’ actions seemed reasonable at the time” (APA Guide, p. 8)
Sensemaking is: Sensemaking is not: • Selecting and naming what seems important about the present, based on: • Past experiences • Past interactions • Collective language • Taking action in the world • Based on how we have “made sense” of the present. • Deciding what is/is not reality (making it up) • The world presents us with brute facts. How do we “make sense” of them and then proceed? Weick, Sensemaking in Organizations, 1995, Sage
Quick Illustration • Brute facts: • Jumping firefighter • Falling tree • Midair collision • Hard landing on rocks
I generally know what I’m doing. Took action Good SA Succeeded (mostly) I know how to (and I did) assess hazards but I was surprised. “A snag fell, I jumped out of the way, I got hit a little bit, and I fell onto some rocks.” Regrettable annoyance Tree fell in a direction I wasn’t expecting. True mechanism of injury Happened earlier than I thought it would. Compare to “I was hit by a tree.” (Sensemaking is: grounded in self concept.)
Alex Shannon • “As a former EMT, this was a ‘high alert’ accident.” • “He knew that the mechanism of injury could cause serious complications.” • “She was limping, but she felt that, as long as she could walk on her own, it would have been ‘weird’ to ask someone to hike two hours in, in order to help her hike 2 hours back out.” Q: Call for Help?
(Sidebars) “Confirmation bias”refers to the human tendency to notice things that confirm our existing beliefs, and to actively ignore details that threaten those beliefs.
Alex Shannon • “Watching her move around put him more at ease.” • “Shannon seemed in control, competent, and confident.” • “She had already decided that the accident had been ‘no big deal,’ and she did not want people to blow it out of proportion.” Confirmation Bias
A: No mention on radio • “Alex felt he could push Shannon, who was his supervisor, only so far into accepting medical assistance.” • “They radioed the lookout, but only to tell him that they were starting their hike out.”
“I was limping. I hiked out. I camped that night. I did not even call home right away.”
Collective sensemaking “Collective” Sensemaking • Past APAs have focused on individual sensemaking • Meadow Creek APA shows how people made sense of events together • Group and local dimensions • Accident • Initial reporting • Initial medical attention • Institutional dimensions • Follow-up medical attention • Different reactions in different regions Appendix B allows you to see what happened to messages about the accident and injury as they were passed along
Group and local unit dimensions (Pull quotes) “If you had fractures, you wouldn’t be able to walk.”
Group and local unit dimensions • Assumption about walking and broken bones: • How do you tell if someone has broken a bone? • “Can you put any weight on it?” • Flipped it around: • “If you had fractures, you wouldn’t be able to walk.” • Therefore, since firefighter was able to walk, there must not have been any fractures. • Confirmation bias
Group and local unit dimensions Disregarding evidence Reaffirming the plan “Alex helped Shannon with the walk out, offering to let her lean on him at times and even cutting footsteps into the sidehill for her.” “As she stepped over logs, Shannon needed to grasp her pant leg in order to lift her right leg.” “As they were walking, they decided that a helicopter would have been too high a risk in the drainage, even with a longline and basket.” “The best anyone could do, they concluded, would be to walk or pack someone out.” Q: Hike out?
Group and local unit dimensions (Questions for the reader) Do you know anyone who hiked out of a fire with a significant injury such as a fracture or a torn ligament?
Group and local unit dimensions Injured firefighter Module 1 leader • Going home next day • Coming up on days off • Can go home and get better on her own • (Former EMT) hospital will probably just give her Tylenol • Is walking, with a limp (i.e., no fractures) • Says she thinks she’s ok “Terry pressed her again, saying ―Shannon, are you sure? Do you want to go to the hospital?” Q: Go to hospital?
Group and local unit dimensions Discussion Point: “Groupthink” Alex: “Once it was decided that she was not going to go to a hospital, the ‘mindset’ seemed to change like the matter had been settled.”
Group and local unit dimensions Jamie: “How much can or should one person do or say to another person who is hurt about making them seek medical care?”
Group and local unit dimensions Question for the reader What would you do if a member of your crew was injured on a fire but refused to seek medical treatment? What if that person was your supervisor?
Group and local unit dimensions Q: Tell others?.... A: selectively “The rest of the module was told that Shannon had ‘taken a digger off a log deck and into some rocks.’” “They understood that she was a little sore and that she just wanted to be left alone.” Module 2 heard: “Someone slipped and fell and might be filling out a CA-1.”
Institutional dimensions Back at the office • Cultural reinforcement • Asked to stand up at District meeting • Praised for “good SA.” • “She hiked out four miles. What a trooper.” • Optimism bias • Bundled messages • “A tree fell on Shannon while GPSing the fireline.” • “She walked off the line.” • “She’s seen a doctor.” • “They haven‘t found anything” (sounds bad initially but succeeding messages temper the impact & express optimism toward the most desired outcome)
Institutional dimensions Now in medical context: “If you had fractures, you wouldn’t be able to walk.”
Pull quote Shannon expected the injuries to go away. She hoped the story would. Neither one happened.
employees use to manage organizational risks 2. language
Perceived organizational risks • Risk of unwanted scrutiny / desire for privacy • Risk of story being blown out of proportion • Risk of investigation
a. Risk of Unwanted Scrutiny Filled out a “precautionary” CA-1. “If you’re not going to go to the doctor, what’s the point of filling one out?” Invites scrutiny Have to keep telling/clarifying story Potential embarrassment
a. Risk of Unwanted Scrutiny “Precautionary” CA-1 • Filled out CA-1 only when decided for sure to see a doctor • At husband’s urging • At that point information becomes “public” • Ok to tell the Module (1) Privacy / HIPPA? Others might expect that all accidents causing injury are being reported.
b. Risk of story being blown out of proportion “It sounds so stupid to say ‘I got hit by a tree’ because that is such a big deal. People get hurt or killed. But I felt I wasn’t that seriously injured.”
b. Risk of story being blown out of proportion On the fire Back at the office • “A snag fell and I jumped out of the way” • “She took a digger off a log deck onto some rocks.” • “Shannon slipped and fell.” • “We had an injury at the bottom…bumps and bruises.” • “Had a little accident…swatted by a tree” • “Brushed by a tree” • “She jumped, a tree caught her in the air, and knocked her to the rocks. • “Tagged” • “Glanced by a tree.” Qualifiers Hit by a tree Avoiding trigger words
b. Risk of story being blown out of proportion Question for the reader How different would your reaction be to hearing someone on your crew had been “hit by a tree,” as compared to hearing someone “slipped and fell”?
c. Risk of investigation “I wonder if…” • What will be the official reaction? • Maybe this accident is not serious enough? • What will my peers say? • “It sounds so stupid to say you were hit by a tree.” • Punitive taint of investigation • “Here we are being investigated anyway” • “Called in for questioning”
c. Risk of investigation “I was just hit by a tree. I’m still alive. I don’t feel that badly injured. I don’t think this counts as that kind of tree strike.”