Building High Reliability Organization(s) (HROs) within the Bureau of Land Management’s Fire/Aviation/Fuels Programs

1. Building High Reliability Organization(s) (HROs) within the Bureau of Land Management’s Fire/Aviation/Fuels Programs Module #2. Communication Fire Photos Courtesy of www.wildlandfire.com

2. Slide Courtesy of US Naval Aviation

3. Lessons learned from the HRO aviation industry acknowledge that most errors are the result of poor communication and coordination rather than individual mistakes

4. Why Communication in Wildland Fire HROs? • The overwhelming majority of untoward events involve communication failures • Somebody knows there’s a problem but can’t get everyone in the same movie • The modern wildland fire environment has evolved beyond the limitations of individual human performance…

5. Examples of Communication Failures: a Past Rx Fire Disaster, a Wildland Fire Accident, and Wildland Fire Use Near Miss

6. 1999, The Lowden Ranch Disaster Catastrophic errors are often the result of the gradual aggregation of small errors across a system. The Lowden Ranch prescribed fire implementation process typified a disaster resulting from communication failures: • Wind speed and one-hour fuel moistures exceeded prescription • The description of fuels was inaccurate • No potential holding problems were identified • All required equipment/personnel were not on scene.

7. The project briefing was inadequate. • A Job Hazard Analysis (JHA) reviewed by the RXB2 only. • Contingency resources were not specifically assigned to the project. • Burn site preparation requirements were not met: Implementation in May or June & line construction specifications • Not all the resources listed in the burn plan were on site.

8. California state burning permit was invalid after July 1, 1999. • Scheduling and notification requirements were not met. • Deteriorating fire weather conditions and spotting were not recognized as an issue nor were they communicated or appropriately acted upon.

9. At approximately 1330, on July 2nd 1999, the Lowden Ranch prescribed fire escaped control and was declared a wildland fire. The Lowden Ranch fire grew to 2,000 acres and destroyed 23 homes.

10. Lowden Ranch Communication Failure Discussion • Little communication up or down the chain of command: • We had some of our best (hotshots, smokejumpers, Rx fire modules) assigned to this project; while they had issues and concerns during implementation (articulated in post disaster interviews), no one said anything… (HRO Failure) • Project team didn’t receive an adequate briefing…They did not have an opportunity to review the Rx burn plan prior to the project… (HRO Failure) • The RXB2 kept burn plan criteria to himself (HRO Failure)

11. HRO defined…Where operational or system failures can result in disaster… (loss of 23 homes) • Field Mger, Zone FMO, and Dispatch: communications, monitoring, oversight was non-existent (HRO Failure) • Notification requirements were not met (HRO Failure) Land owners adjacent to, and in the vicinity of, the burn were not notified. The news media was not notified 72 hours in advance as specified in the burn plan.

12. Engine 494 Roll-Over Accident

13. Background Information • In August, 2005, Wyoming BLM Engine 494 was involved in a roll-over accident just North of the Utah boarder. • The Engine crew (both engine module leaders on light duty status) had just completed gathering live fuel samples… • As E494 completed their fuels mission, they were instructed to relocate to initiate a “windshield” size up of four reported fires.

14. The employees made the decision to leave the pavement & drive on a (mud/clay) road immediately after a high intensity thunderstorm went through the area. • The engine was traveling down a slight hill and failed to negotiate a curve. The vehicle slipped down a 12 foot gully and ended doing a quarter role. The resulting accident injured both passengers. • The tires used became “caked” with mud and clay…This was a factor resulting in lost traction and control of the vehicle

16. Engine 494 Communication Failure Discussion • Both Engine Module leaders were our some of our “best”… Fourteen seasons experience with knowledge of the country, equipment, conditions… • Both confided they were concerned about road conditions & leaving the pavement…Yet, didn’t communicate concerns to one another, Dispatch or FMO… (HRO Communication Failure)

17. Near Miss…Little Venus Entrapment Communication Failures

18. General Communication problems: • Poor communication led to uncertainty as to whether Unaweep & the packers had received information having them stage downstream from the fire. • Poor communication led to erroneous information concerning the disposition of Unaweep during the fire’s major run. • Poor communication prevented knowledge of the shelter deployment until after the firefighters had emerged from their shelters. • Poor communication caused a high level of confusion and additional risk after the deployment concerning the disposition of all the firefighters.

19. It concerned many individuals that one of the packers was a 14 year old boy and neither packer had a fire shelter, hard hat or nomex. Yet, nothing was said or done… • Before they left the lead packer was given a radio. When turned on, the radio displayed a “LOWBATT” warning. The packer turned the radio off… Again, nothing said or done…

20. The packers were ahead of the module, with no communications. The only way that Unaweep could communicate with them was to overtake them on the trail.

21. Some members of Unaweep were concerned with starting their hike so late in the day. Yet, nothing was said or done… • As fire activity picked-up, the Black Hills module leader was concerned that it seemed no one in operations was directing Unaweep to stay out of the Greybull River canyon. • After several attempts, the Black Hills module look outs finally made contact with Unaweep…. Unaweep replied to the lookout that they would find the packers and then find a place to stage up Anderson Creek. • All BlackHills could hear is static in reply.

22. A module member cuts off the trail towards the river, pulls her fire shelter out of her pack and drops her pack. No information or communication passed along to the Unaweep Module leader. • At the Anderson Creek Deployment site a head count was conducted, and then multiple recounts, one firefighter was missing.

23. At 1618 ICP asked Black Hills if they had communications with Unaweep. Black Hills lookouts responded that they had communications earlier with Unaweep and that Unaweep was headed back down the river. • Black Hills relayed that they didn’t have current communications with Unaweep.

24. After the deployment, countless attempts were made to contact ICP, the missing firefighter and the Black Hills Module, were made; one of the firefighters at the Anderson Creek Deployment Site was finally able to make contact with ICP… • Helicopter support was requested by ICP to find the missing module member…

25. Radio communications from ICP and the helibase were not working at this time. • A firefighter overhearing relayed the conversation to the helibase mger. • Flying in 30 to 50 knot winds, the pilot of a restricted Type 2 helicopter and the helibase/helicopter manager initiate a search and rescue mission

26. Flying into the edge of the fire plume, the type II helicopter pilot and manager realized their efforts were useless. • The single firefighter at the Greybull River Deployment Site heard the helicopter on the air to ground frequency and successfully called helicopter • The firefighters at Anderson Creek heard her call the helicopter.

27. Little Venus Communications Overview • With good radio communications, the Little Venus near miss would most likely have been avoided… • …What’s even more problematic, our personnel continue to see problems (incubation signs for a disaster or accident), yet, nothing is said or done

28. Some possible communication failure causal factors • Our focus on wildland fire leadership and operating cultures have evolved over time… The “chain-of-command” is very strong…Leadership is absolute!

29. When in Rome, do as the Romans do…Even if it doesn’t follow policy… Don’t make waves… • Mission accomplishment is still our # 1 priority…Even over safety • Task fixation • Task overload • Our leaders are often left to make decisions in a vacuum because of a lack of input from subordinates • Perception of respectful input and communications as “conflict”…Most want to avoid this…

30. An HRO hallmark: understanding the importance of effective and varied communication. Communication in HROs provides one means of understanding roles, responsibilities, and relationships in the System (Roberts, 1993b) • Communication provides opportunities to discuss improvements in the system, including risk mitigation strategies or approaches, as well as what the probable impacts of different risk mitigation measures might be (Roberts, Grabowski 1996) • In my opinion, we have not achieved the communication characteristics of a HRO.

31. …So, where do we go from here?

32. Changing our Wildland Fire/Fuels/Aviation culture, supporting HRO communications • Culture is a pattern of shared assumptions about the organization's values (what is important), beliefs (how things work), and behaviors (the way we do things) • While employees hold varying attitudes, beliefs, and cultural assumptions… Typically “culture” embodies the philosophies of senior leaders. • It starts with us as leaders, we need to promote & encourage HRO style communications

33. We have the processes, tools and training in Place…To name a few: • Crew Resource Management Training/Literature • After Action Reviews • The staff ride concept • A good briefing process before and after critical events • The Wildland Fire Leadership Development Program • L-180, L-280, L-380 (Mission Centered Solutions/NOLs advanced leadership training)

34. Effective leaders establish and reaffirm norms for behavior in the group, and insist the people keep each other informed on what they were doing and the reasons for their actions, and the situational model that gave rise to those reasons and actions (This would include saying): • Here’s what I think we face • Here’s what I think we should do • Here’s why • Here’s what we should keep our eye on • Now talk to me (Weick, 1995; pp.3-4)

35. Options we’re considering in Wyoming • “Skills-both physical and mental-are improved through practice…Recent studies of the acquisition of skills by expert performers explicitly highlight the role of good practice and good instruction. Learning to do things correctly (and seeking good feedback) and practicing the correct way makes good sense. (Hogarth, Educating Intuition)…Develop HRO Fire Communication Simulations… • Evaluation of HRO style communications as part of local and state readiness reviews

36. Required reading for modules…Crew Resource Management a Positive Change for the Fire Service… • Required training L-180, L-280, L-380 • Annual Staff Rides for each Fire Management Zone • Development of Engine Cab Resource Management principles and techniques • Continued focus on solid briefing practices and AARs