communication in the wildland fire environment with selected lessons from the meadow creek fire apa...

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

I. Accident Prevention Analysis (APA) II. Meadow Creek Fire APA The Story APA Team Lessons Learned Analysis Collective Sensemaking III. Reflections on the APA Process

I. ACCIDENT PREVENTION ANALYSIS APA

APA Alternative prototype accident investigation (USDA FS) Predicated on Just culture Reporting culture Learning culture Promise of no punitive action

APA, contd. 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?

II. MEADOW CREEK FIRE APA July 2010

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 Accident Site Fire Origin Lookout 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 Risk Management Reporting Sensemaking Individual Collective Group and Local Institutional

Sensemaking Lessons 1. Collective sensemaking is a truly social process. Begins with the individual Requires the input of many people 2. Employees use language to manage risks that emerge from the organizational environment. 3. Perceptions of leaders can influence upward and lateral voice. 4. Life happens. And can challenge expectations for clear and timely communication.

1. COLLECTIVE SENSEMAKING A Truly Social Process

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

Brute facts: Jumping firefighter Falling tree Midair collision Hard landing on rocks Quick Illustration

A snag fell, I jumped out of the way, I got hit a little bit, and I fell onto some rocks. Compare to I was hit by a tree. Regrettable annoyance Succeeded (mostly) Good SA Took action True mechanism of injury Tree fell in a direction I wasnt expecting. Happened earlier than I thought it would. I generally know what Im doing. I know how to (and I did) assess hazards but I was surprised. (Sensemaking is: grounded in self concept.)

Q: Call for Help? AlexShannon 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.

Confirmation bias refers to the human tendency to notice things that confirm our existing beliefs, and to actively ignore details that threaten those beliefs. (Sidebars)

Confirmation Bias AlexShannon 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.

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 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 Collective sensemaking

If you had fractures, you wouldnt be able to walk. Group and local unit dimensions (Pull quotes)

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 wouldnt 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

Q: Hike out? Disregarding evidenceReaffirming 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. Group and local unit dimensions

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 (Questions for the reader)

Q: Go to hospital? Injured firefighterModule 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 shes ok Group and local unit dimensions Terry pressed her again, saying Shannon, are you sure? Do you want to go to the hospital?

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 Discussion Point: Groupthink

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

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 Question for the reader

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. Group and local unit 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. Shes seen a doctor. They havent found anything Institutional dimensions (sounds bad initially but succeeding messages temper the impact & express optimism toward the most desired outcome)

If you had fractures, you wouldnt be able to walk. Institutional dimensions Now in medical context:

Shannon expected the injuries to go away. She hoped the story would. Neither one happened. Pull quote

2. LANGUAGE employees use to manage organizational risks

Perceived organizational risks a) Risk of unwanted scrutiny / desire for privacy b) Risk of story being blown out of proportion c) Risk of investigation

Filled out a precautionary CA-1. If youre not going to go to the doctor, whats the point of filling one out? Invites scrutiny Potential embarrassment Have to keep telling/clarifying story a. Risk of Unwanted Scrutiny

Precautionary CA-1 Filled out CA-1 only when decided for sure to see a doctor At husbands 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. a. Risk of Unwanted Scrutiny

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 wasnt that seriously injured. b. Risk of story being blown out of proportion

Avoiding trigger words On the fireBack 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 bottombumps and bruises. Had a little accidentswatted 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. Hit by a tree Qualifiers b. Risk of story being blown out of proportion

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? Question for the reader b. Risk of story being blown out of proportion

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. Im still alive. I dont feel that badly injured. I dont think this counts as that kind of tree strike. c. Risk of investigation

3. LEADERSHIP Impact of perceptions on lateral and upward voice

Q: Fill in? Had legitimate authority I took the crew to set up the webcam. Joe and Jamie were in charge but Shannon could have vetoed them. Even Module 2 noticed: The woman who led that crew up the drainage. Expectations for leader transparency A challenging question, but evidence points to no.

Q: Fill in? Actually influenced subordinates Convinced Jamie and Alex not to tell the lower level crew members: Does she need to go to a doctor? Well, I think she does, but (self silencing) Demonstrated lateral influence as well Module leader trusted her judgment about going to hospital Expectations for leader transparency A challenging question, but evidence points to no.

Terry later admitted that he wished he had trumped Shannons decision to downplay the accident. Expectations for leader transparency

However Shannons perception of herself as a leader did not seem to match subordinates perception of her actual level of influence.

Different Expectations ShannonCrew Being a fill-in, Shannon may have perceived her injury as a private matter. No big deal. Didnt know* if the whole module needed to know. But the crew had higher expectations for her to share information with them. If someone is injured on the crew, I think I have a right to know about it. It sucks not knowing. We would like to have known what to do to help. *in retrospect now believes they did need to know of the hazard of unexpected falling trees Expectations for leader transparency

LL from participants Upward voice When an accident happens use the chain-of- command to report the accident and get that outside perspective. Call the IC to let them know about the accident. Tell the IC she can walk out and ask if there was something else that we should do. Expectations for leader transparency

LL from participants As a leader, cultivate a culture of reporting If someone is hurt, the appropriate management response is to get you better. Well work the lesson later. Tell the crew, you wont get in trouble. We understand things happen, we just want to take care of you. As an IC, follow up to ensure that the CA-1 was filed and that the person went to the doctor. Expectations for leader transparency

A Leader of others but not one who is also led? Leaders we spoke with seemed very clear about how they would act with an injured subordinate: If it was anyone who worked for me, I would have made them go to the hospital. If this was a seasonal I would never have given them the choice to not report or send them to the doctor. But they seem to have difficulty imagining themselves as someone elses subordinate. Difficulty taking their own leaders perspective as someone who might be concerned about them. Leaders taking risks

As a leader, do you take more risks than you would allow of those who work for you? Leaders taking risks Question for the reader

4. COMMUNICATION Lifes Challenges to Timely and Clear

Timely Communication Injured firefighterAround the office Pain Navigating the rules of a system new to them OWCP case Rules regarding providers and coverage Absence from the office Gaps in continuity Annual leaves, people travel Reliance on asynchronous technology Phone messages Email Communication

Clear Communication Unfamiliar with reporting requirements How much detail to include Who to send it to Assuming everyone else is on same page Some heard more details than others But did not take the time to check each others facts I saw Shannon. She looked hurt and went home. There was an accident involving Shannon. Did you hear about Shannon? Extension of timely issues Communication

Recap 1. Collective sensemaking is a truly social process. Begins with the individual but Requires the input of many people 2. Employees use language to manage risks that emerge from the organizational environment. 3. Perceptions of leaders can influence upward and lateral voice. 4. Life happens. And can challenge expectations for clear and timely communication. Read, reflect upon, and discuss the report with others.

III. REFLECTIONS On the APA Process as a Participant

Initial Skepticism Who said anything about needing to learn a lesson? Set up alternate approaches carefully Organizational Learning High reliability Inferential leap from their story to team conclusions Be clear about framework for analysis

First Hand Observations Power of promise of no punitive action Interview as a learning experience Cultural intervention A story for learning Cultivating a vocabulary for understanding culture

Individual Sensemaking Positive Self-conception Minimization Cultural influences Worst case scenario with hazard trees Confirmation bias Initial belief about extent of injury Concern about risks to others Desire to avoid the spotlight Note: personality traits might be representative of the broader culture

Collective Sensemaking: Group and Local Unit Influence over subordinates and peers Status can influence medical care decisions Timing of the accident (not fatigue, but) coming up on days off CA-1 delay Contingency of seeking medical care How language can influence meaning Ducking trigger words Qualifiers

Institutional Dimensions Medical Misdiagnoses Confirmation bias Cognitive dissonance Reactions in the home unit Barriers to timely and clear communication Personalization to the injured firefighter Reactions in the host unit Knee jerk reaction Simultaneous notice accident as tree strike and injury as broken bones (trigger words) Surprise, bafflement, indignation, allegations of lying

APA as a Work in Progress Peer Review to APA Guide updated annually Workshops Report innovations Pseudonyms Gender neutral names Pull quotes Questions for the reader Discussion points

Ongoing challenges (+/-) Interview as data Discursive analysis (direct quotes) Limited by willingness to share, hindsight bias Meaning of a collective account Everyones story, but nobodys story in particular May challenge expectations for narrative fidelity and narrative probability

Ongoing challenges (+/-) Widespread organizational learning Reliance on individual readers? Converting to other modes of learning Cultural acceptance of APA or other alternative approaches Damaged trust Compliance/punishment climate for safety

I. Accident Prevention Analysis (APA) II. Meadow Creek Fire APA The Story APA Team Lessons Learned Analysis Collective Sensemaking III. Reflections on the APA Process

Thank you! Questions or Comments? 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

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