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
“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 5August 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
RAWS
Private
Lookout
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
1.
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.
3. Perceptions of leaders can influence
upward and lateral voice.
4. “Life happens.” And can challenge
expectations for clear and timely
communication.
2.
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:

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.
Weick, Sensemaking in
Organizations, 1995, Sage
Sensemaking is not:

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?
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
I know how to (and I did) assess hazards
but I was surprised.
Regrettable
annoyance
Succeeded (mostly)
“A snag fell, I jumped out of the
way, I got hit a little bit, and I
Tree fell in a direction I wasn’t
expecting.
fell onto some rocks.”
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
Appendix B allows you to
see what happened to
messages about the
accident and injury as they
were passed along
 Follow-up medical attention
 Different reactions in different regions
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 they were walking, they
decided that a helicopter
would have been too high a
risk in the drainage, even with
a longline and basket.”
“As she stepped over logs,
Shannon needed to grasp her
pant leg in order to lift her
right leg.”
“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?....
“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.”
A: selectively
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.”
(sounds bad initially
but succeeding messages
“She’s seen a doctor.”
temper the impact
“They haven‘t found anything” & 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
a)
b)
c)
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
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 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
rocks.”
Hitonto
bysome
a tree
 “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”
Qualifiers
“She jumped, a tree caught
her in the air, and knocked
her to the rocks.
“Tagged”
“Glanced 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.”
Impact of perceptions on lateral and upward voice
3. LEADERSHIP
Expectations for leader transparency
Q: Fill in?

A challenging question, but evidence points to “no.”
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
Q: Fill in?

A challenging question, but evidence points to “no.”
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
“Terry later admitted that he
wished he had trumped
Shannon’s decision to downplay
the accident.”
Expectations for leader transparency
However…
Shannon’s perception of herself
as a leader did not seem to
match subordinates’ perception
of her actual level of influence.
Expectations for leader transparency
Shannon

Crew
Being a fill-in, Shannon
may have perceived her
injury as a “private”
matter.

◦ “No big deal.”
◦ “Didn’t know* if the
whole module needed to
know.”
*in retrospect now believes they did need to
know of the hazard of unexpected falling trees
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.”
Different Expectations
Expectations for leader transparency
LL from participants

Upward voice
◦ “When an accident happens use the chain-ofcommand 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.
We‘ll work the lesson later.’”
◦ “Tell the crew, ‘you won‘t 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.
Leaders taking risks
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 else’s
subordinate.
◦ Difficulty taking their
own leader’s perspective
as someone who might
be concerned about
them.
Leaders taking risks
Question for the reader
As a leader, do you take more
risks than you would allow of
those who work for you?
Life’s Challenges to “Timely” and “Clear”
4. COMMUNICATION
Communication
Injured firefighter
Around the office
Pain
 Navigating the rules of a
system new to them


◦ OWCP case
◦ Rules regarding providers and
coverage

Gaps in continuity
◦ Annual leaves, people travel

Reliance on asynchronous
technology
◦ Phone messages
◦ Email
Absence from the office
“Timely” Communication
Communication
“Clear” Communication

Unfamiliar with reporting requirements
◦ How much detail to include
◦ Who to send it to

Extension of
“timely” issues
Assuming everyone else is on same page
◦ Some heard more details than others
◦ But did not take the time to check each
other’s facts
 “I saw Shannon. She looked hurt and went home.”
 “There was an accident involving Shannon.”
 “Did you hear about Shannon?”
Recap
1.
Collective sensemaking is a truly social
process.
◦ Begins with the individual but
◦ Requires the input of many people
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.
2.
On the APA Process as a Participant
III. REFLECTIONS
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
◦ Everyone’s story, but…
◦ …nobody’s 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