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
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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
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I. ACCIDENT PREVENTION ANALYSIS APA
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APA Alternative prototype accident investigation (USDA FS)
Predicated on Just culture Reporting culture Learning culture
Promise of no punitive action
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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?
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II. MEADOW CREEK FIRE APA July 2010
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Timeline July 5: Accident July 30: Discovery Aug 3: Team
convened My role: SME Organizational Communication and Culture
September 28: Report completed
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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
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Key sections The Story Participant Lessons Learned APA Team
Lessons Learned Analysis
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Key sections The Story The Accident Follow up Reporting The
Accident
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Web cam Accident Site Fire Origin Lookout RAWS Private
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Key sections The Story The Accident Follow up Reporting Follow
up Reporting
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Key sections The Story Participant Lessons Learned APA Team
Lessons Learned Analysis
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Key sections The Story Participant Lessons Learned APA Team
Lessons Learned Analysis
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Key sections The Story Participant Lessons Learned APA Team
Lessons Learned Analysis Risk Management Reporting Sensemaking
Individual Collective Group and Local Institutional
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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.
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1. COLLECTIVE SENSEMAKING A Truly Social Process
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Why sensemaking? where employees made mistakes what should have
been done illuminate why employees actions seemed reasonable at the
time (APA Guide, p. 8)
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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
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Brute facts: Jumping firefighter Falling tree Midair collision
Hard landing on rocks Quick Illustration
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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.)
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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.
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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)
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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.
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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.
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I was limping. I hiked out. I camped that night. I did not even
call home right away.
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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
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If you had fractures, you wouldnt be able to walk. Group and
local unit dimensions (Pull quotes)
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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
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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
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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)
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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?
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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
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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
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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
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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
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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)
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If you had fractures, you wouldnt be able to walk.
Institutional dimensions Now in medical context:
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Shannon expected the injuries to go away. She hoped the story
would. Neither one happened. Pull quote
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2. LANGUAGE employees use to manage organizational risks
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Perceived organizational risks a) Risk of unwanted scrutiny /
desire for privacy b) Risk of story being blown out of proportion
c) Risk of investigation
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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
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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
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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
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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
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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
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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
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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
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3. LEADERSHIP Impact of perceptions on lateral and upward
voice
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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.
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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.
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Terry later admitted that he wished he had trumped Shannons
decision to downplay the accident. Expectations for leader
transparency
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However Shannons perception of herself as a leader did not seem
to match subordinates perception of her actual level of
influence.
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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
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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
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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
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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
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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
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4. COMMUNICATION Lifes Challenges to Timely and Clear
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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
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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
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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.
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III. REFLECTIONS On the APA Process as a Participant
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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