Lessons Learned Report: by 3iq4TGM1

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									                             Lessons Learned Report:
                 All Hands Meeting – Leadership and Mindfulness
        Klamath National Forest Fire & Aviation Management, Yreka, California
                                   April 14-18, 2008

Introduction:

During the week of April 14 to April 18, 2008, the Klamath National Forest (KNF) held a weeklong
workshop emphasizing leadership development, teamwork, communication, and high reliability organizing
(HRO) principles. The workshop’s planners organized the session around a central principle of
integrating the concepts of leadership and mindfulness; with emphasis on implementing and applying
both in the operating environment.

The target audience included all KNF fire and fuels personnel, KNF personnel contributing to the fire and
aviation program as a collateral duty, and the KNF Leadership Team. Approximately 90 personnel
attended the workshop, including line officers and staff both from the Forest and the ranger districts and
representatives of all KNF crews and modules, among others. Several subject matter experts from
outside the KNF fire and aviation organization contributed to the week’s content. The organizers
established the following goals and objectives for the workshop:

Goals

 Continue developing a Forest team that understands and respects the roles and responsibilities in
  wildfire management

 Enhance communication

 Build leadership capacity at all levels of the fire organization

 Continue to bring the KNF fire organization together to unify our leadership

Objectives

 Demonstrate examples of High Reliability Organizing (HRO) and mindfulness in fire operations

 Enhance cohesion by providing a forum that encourages open communication

 Improve our understanding of what leadership is

 Create an understanding of how mindfulness is a component of leadership

This report summarizes the workshop, documents lessons learned, and offers recommendations for
improving future workshops. The workshop agenda is attached as an appendix to this report.




                                                                                                             1
Summary of the Week’s Activities

Considering the diversity of the target audience (GS-3 Apprentice Firefighters to the Forest Supervisor),
one would expect difficulty pleasing everyone. This year, the workshop organizers were faced with the
added challenge of making late content substitutions as planned presenters dropped out. Despite these
challenges, all indications are that the week was a success and a valuable use of the Forest’s human and
financial resources.

Riva Duncan, Acting Forest Fire Management Officer and Patty Grantham, Acting Forest Supervisor
opened the workshop with a welcome, opening remarks and a discussion of emerging issues including
hiring and retention.

After lunch on the first day, the session moved toward its central organizing principle, with a discussion of
the principles of HRO/mindfulness, with the intent of reorienting people to the topic and preparing them to
apply the principles to case studies, brief practical examples, the Lowden Ranch staff ride, and other
activities throughout the week. That afternoon, participants presented case studies of the Elk Complex
helicopter accident (KNF, 2007) and the Angora Fire Accident Prevention Analysis (APA). The
organizers conducted an AAR afterward.

On Tuesday, the Chaplain of the Siskiyou County Sheriff’s Office presented information on managing
critical incidents. The facilitator made an effort to frame this discussion in the context of the HRO
principles, particularly commitment to resilience. Afterward, the Assistant Director, operations, R-5 Fire
and aviation Management (North Ops) presented news from North Ops, with a particular emphasis on
clarifying the Forest Service’s roles, responsibilities, authorities and policy regarding structure protection
in the wildland-urban interface.

The group rounded-out the morning with a presentation on HRO and the Cascade II escaped prescribed
fire. After lunch, the workshop continued with its HRO/mindfulness theme with several practical examples
of mindfulness including examples from the Moonlight Fire, the Investigation of the Elk Complex
helicopter accident, and numerous interesting examples from the audience. The day concluded with a
presentation linking leadership concepts with the principles of HRO/mindfulness and a transition to the
workshop’s staff ride. The organizers conducted an AAR afterward.

On Wednesday, following a discussion of staff ride logistics; the assembled group conducted the
preliminary phase of the Lowden Ranch staff ride. After a lunch break, the workshop participants spent
the rest of the day traveling to Redding in preparation for the staff ride. Staff ride cadre members
conducted a planning session and “dry run” of the Lowden Ranch staff ride. Workshop participants broke
out by division for dinner.

On Thursday, the workshop participants conducted a staff ride of the Lowden Ranch escaped prescribed
fire near Lewiston, CA, which burned down 25 nearby homes in 1999. It was the intent of the workshop
organizers that; with mindfulness training and the Rattlesnake Fire staff ride conducted during the all-
hands meeting in 2007 and the mindfulness and leadership presentations of this year’s workshop as
background, that the participants on the Lowden Ranch staff ride would be able to view the 1999 escaped
prescribed burn through a lens of HRO/mindfulness principles. The organizers also hoped that the staff
ride experience would enable the participants to enhance their safety awareness during the 2008 fire
season, and continue to develop their understanding of HRO. On their return to Yreka, the staff ride
participants were offered an opportunity to participate in an after action review (AAR) of the staff ride, the
results of which are documented in this report.

On Friday, the last day of the workshop, the participants conducted the integration phase of the Lowden
Ranch staff ride and, following a brief overview of the week and wrap-up, completed evaluations of the
workshop and departed from a successful week. The organizers conducted a final AAR. The results of
the workshop evaluations and final AAR are documented in this report.




                                                                                                                 2
Goals

Continue developing a Forest team that understands and respects the roles and responsibilities in wildfire
management

Enhance communication

Build leadership capacity at all levels of the fire organization

Continue to bring the KNF fire organization together to unify our leadership

Objectives

Demonstrate examples of High Reliability Organizing (HRO) and mindfulness in fire operations

Enhance cohesion by providing a forum that encourages open communication

Improve our understanding of what leadership is

Create an understanding of how mindfulness is a component of leadership

Agenda

Monday, April 14 – Yreka Community Theater

10:00 - 10:15        Welcome and Preliminary Remarks – Riva Duncan, Acting Forest FMO

10:15 - 10:45        Opening Remarks - Patty Grantham, Acting Forest Supervisor

10:45 -11:00         Break

11:00 - Noon         Emerging Issues Including Retention – Riva Duncan & Patty Grantham

Noon-13:30           Lunch (Cookout) at Lower Greenhorn Park

13:30-14:45          Mindfulness/HRO - Mike DeGrosky, Guidance Group, Inc

14:45-15:00          Break

15:00-16:00          Case Study: Elk Complex Helicopter Crash – Richard Wilson

16:00-17:00          Angora Fire APA – Ray Haupt, Team Leader

17:00                AAR (organizers)



                                                                                                         3
Tuesday, April 15 – Yreka Community Theater

08:00-09:30           Managing Critical Incidents – Keith Bradley, Siskiyou County Sheriff’s Office (with
                      HRO/mindfulness context by Mike DeGrosky, Guidance Group, Inc)

09:30-09:45           Break

09:45-10:45           News From North Ops - Joe Millar, Assistant Director, Ops - FAM

10:45-10:55           Short Break

10:55-12:10           HRO and Cascade II Escaped Prescribed Fire - Riva Duncan, Acting Forest FMO

12:10-13:10           Lunch

13:10-13:40           Practical Example of Mindfulness, Moonlight Fire (Aaron Schuh)

13:40 –14:10          Practical Example of Mindfulness, Crew Level

14:10-14:40           Practical Example of Mindfulness: Helicopter Investigation (Patty Grantham)

14:40-15:10           Practical Examples of Mindfulness, open to the group

15:10-15:25           Break

15:25-16:45           HRO/Leadership Wrap-up and Transition to Staff Ride, Mike DeGrosky, Guidance
                      Group, Inc

AAR (organizers)

Wednesday, April 16 – Yreka Community Theater

08:00-08:15 Staff Ride Logistics – Helen Smith, Logistics Section Chief

08:15-10:45 Staff Ride Preliminary Phase - Mike Powell & Aaron Schuh

10:45-Noon Prepare to Leave for Redding and Lunch (on own)

Noon-16:00 Travel

Evening:      Division Breakouts for Dinner

Thursday, April 17

Lowden Ranch Staff Ride (All Day)

Return Travel

Friday, April 18 – Fairgrounds, Floral Room

09:00 – 11:00 Staff Ride Integration Phase - Mike Powell & Aaron Schuh

11:00-Noon Wrap-up and Close-Out -Closing Remarks/Evaluation




                                                                                                            4
Mindfulness/HRO

The presentation on mindfulness/HRO addressed the five principles of mindfulness:

1. Preoccupation With Failure
2. Reluctance to Simplify
3. Sensitivity to Operations
4. Deference to Expertise
5. Commitment to Resilience
The intent of the presentation was to reorient the workshop participants to the concepts and language of
mindfulness and HRO; relate the concepts and language to the practical, operational environment; and
prepare the workshop participants to apply the concepts and languages to case studies, practical
examples, and the Lowden Ranch staff ride.

Case Study: Elk Complex Helicopter Crash

Richard Wilson (Superintendent), Will Johnson (Captain) and Nick Linfoot (Apprentice Firefighter) of the
Happy Camp Crew spoke about their experiences pertaining to the Elk Complex helicopter accident, to
which they were eyewitnesses and direct participants.

Case Study: Angora Fire APA

Ray Haupt (District Ranger – Scott/Salmon and Acting Deputy Forest Supervisor) spoke about his
experiences on the Angora Fire as the leader of the Accident Prevention Analysis (APA) Team. Key
points included:

 The critical importance of situational awareness on the fireline

 The dangers of uncontained performance pressure (“If we don’t pick-up these spots, homes will burn).
  Urgency: Billions of dollars worth of real estate threatened

 Two hours prior to the entrapment, the IHCs assigned to the fire withdrew based on their observation
  and assessment of weather conditions

 The risk of unclear direction (how far to go down a road to pick-up spots)

 The people in charge were highly distracted by the politics of the situation and the media created a
  distraction on the fireline

Managing Critical Incidents

Following a brief introduction to tie the presentation topic to the HRO/mindfulness principle of commitment
to resilience, Keith Bradley (Chaplain, Siskiyou County Sheriff’s Office) addressed the topic of managing
critical incidents including a primer on stress, a discussion of the differences (and relationships) between
critical incident stress management (CISM) and critical incident stress debriefings (CISD), the importance
of peer support, and the difference between grief counseling and CISD. The Chaplain’s key points are
included in a pamphlet called Critical Incident Stress Debriefing Team: Serving Those Who Serve
Siskiyou County Law Enforcement, Fire, EMS. This pamphlet is available from the Siskiyou County
Sheriff’s Office.




                                                                                                           5
News From North Ops

Joe Millar (Assistant Director, Operations R-5 FAM) began by speaking about the importance of FSM
5130 and the California Fire Management Agreement (CFMA) as the basis of an annual operating plan).
He moved on to a discussion of structure protection, making important distinctions between performance
and responsibility. Key points:

 Responsibility is authority and jurisdiction (not moral authority)

 Performance is what we actually do. We will still respond and act. The FS will still respond in support
  per FSM 5132 and CFMA.

 Dual responsibility describes the nature of Forest Service fire protection within CDF SRAs. The Forest
  Service is the primary protector of vegetation and CDF is the primary protector of structures. However,
  Forest Service mission and CFMA allows Forest Service to protect structures and the Forest Service
  can expend Federal funds on structure protection before the fire reaches the structure when acting in
  concert with others with jurisdiction or when requested.

Joe wrapped up with a discussion of resource movement and prioritization.

HRO and the Cascade II Escaped Prescribed Fire

Riva Duncan (Deputy Forest FMO and Acting Forest FMO) spoke about her personal experiences
associated with the Cascade II escaped prescribed burn in Utah, relating lessons learned from her
experience to the principles of HRO. Riva was new to her job, having been in-place for four months, and
had not been involved in the burn planning, and filled the position of Ignition Specialist two days prior to
the burn. There had been two previous, unsuccessful attempts to burn, the fiscal year end was
approaching, and a sense of urgency and performance pressure surrounded the operation. Burn unit
boundaries had been altered without amending the burn plan. Key points included:

The personal impacts of such an event

How these events constitute an abrupt and brutal audit. How, in a moment’s notice, everything left
unprepared for becomes a complex problem and every problem comes rushing forward

How the events of the Cascade II burn can effectively demonstrate the five principles of
mindfulness/HRO; preoccupation with failure, reluctance to simplify, sensitivity to operations, deference to
expertise, and commitment to resilience. The case study presented numerous effective examples of
each.

How three of the four elements of Winston Churchill’s self-conscious audit applied to the situation
  Why didn’t I know?
  Why wasn’t I told?
  Why didn’t I ask?

Personal resilience:
  Realize and analyze personal mistakes
  Utilize support systems
  Share lessons learned
  Keep it in perspective
  Get back on the horse




                                                                                                            6
Key Lessons Learned:
  Follow your gut
  Speak-up even if it’s painful
  Be willing and ready to make unpopular decisions
  Pay attention to the weak signals
  Work hard to establish trust
  Utilize people who have the skills you need

Practical Example of Mindfulness: Moonlight Fire

Aaron Schuh (Battalion Chief, BC 21 Suppression Battalion - Happy Oak Ranger Districts) spoke about
his personal experiences as a Division Supervisor Trainee on the Moonlight Fire on the Plumas National
Forest in 2007. Aaron spoke of how he deferred to expertise (to an IHC Superintendent assigned to his
Division) to serve as a line scout, to collect field intelligence, and to help improve Aaron’s situational
awareness. He also related his experience to the HRO/mindfulness principle of commitment to resilience.
On this fire, the fire behavior over-ran the plan, but the Division organization recognized that and
recovered, rather than sticking to their plan. The described situation also demonstrated sensitivity to
operations. People were on the ground, looking for weak signals, they knew the details of their operation
and they asked themselves “What are we doing and how does that compare to what we should be
doing?”

Practical Example of Mindfulness: Elk Complex Helicopter Accident Investigation

Patty Grantham (Deputy Forest Supervisor and Acting Forest Supervisor) discussed her experiences
associated with the investigation team on the Elk Complex helicopter accident in 2007. She recounted
how she informed the Serious Accident Investigation Team that they could not fly in the Forest’s
helicopter, both because the requested mission lay far outside the Forest’s standard operating
procedures and the mission would take the helicopter out of initial attack availability. Patty took this
action despite pressure from the investigation team and despite the fact that her actions were interpreted
as some as an effort to hamper the investigation. Key points from this experience include:

   Line officers must defer to expertise (Patty relied on her fire and aviation staff for the right course of
    action)

   Investigation teams must defer to the expertise of local personnel

Practical Examples of Mindfulness:

Participants in the workshop presented numerous practical examples of mindfulness. Among the
experiences discussed, examples of preoccupation with failure and weak signals included:

     A briefing that takes two hours
     Controversy over where to ignite a prescribed burn
     A Division Chief concerned about burning with a pickup team
     A Superintendent has a hunch that he should be watching a helicopter operation closely

Examples of sensitivity to operations included:

   Recognizing who is in the best position to know, when it comes to aviation operations
   A DIVS (T) having people out there looking, knowing the messy details of the operation
   Wanting to know what’s happening with seasonal employees involved in critical incident




                                                                                                                 7
Practical Examples of Mindfulness - Continued

Examples of deference to expertise included:

   A Division Chief makes the call about whether to burn or not
   A Division Supervisor has a subordinate IHC Superintendent update his SA
   You become the “go-to” people when you are trustworthy, credible with knowledge, experience and
    training

Examples of commitment to resilience included:

   Recognizing when a plan is untenable, giving it up, recovering
   A line officer declines an investigation team’s request to fly in the helicopter, even when some take
    that as a sign that they are hampering the investigation

Preliminary Phase: Lowden Ranch Staff Ride – Pre-Reading

The Lowden Ranch Prescribed Fire Review (Final Report) is available on-line from the Wildland Fire
Lessons Learned at URL:

http://www.wildfirelessons.net/documents/Lowden_Ranch_Rx_Fire_Review_1999.pdf

All pre-reading materials for the Lowden Ranch staff ride were drawn from these materials

Preliminary Study Phase: Lowden Ranch Staff Ride – Discussion Outline

Review of Staff Ride Logistics

Overview of Staff Rides

   Why are they important to you
   History of staff rides
   How they fit in with HRO

Lowden Ranch Staff Ride

  Why is this staff ride important to you

  Objectives

     Develop RPD Slides
     Lessons Learned
     Not Just for Burn Bosses

  Stand Presenters were involved with the Incident

       Chief Ron Marley – Suppression Team Member, Investigation
       Gerry Spence – Lead Jumper, Running an Ignition Team
       Glen Warner – Fire Use Module Leader, RXI2
       Rob Holt – Diamond Mountain Hotshots, Holding Specialist
       Kristy Ralston – Diamond Mountain Hotshots, Crewmember
       Johnny Clem, Klamath Hotshots, suppression resource (Redding Hotshots)

    Each of these people has a different perspective and provides a different set of personal lessons
    learned




                                                                                                            8
Preliminary Study Phase - Continued

  Application of HRO

  Pre-Reading Review

      Project Background

      Project objectives

      Area orientation – Google Earth overview

      Resources Background – experience and personalities if known

           BLM Fire in Redding
           Burn Boss, Doug Held, Pressure to perform
           Burn Boss Trainee, Bob Perez
           Whiskeytown Fire Use Module
           Diamond Mountain Hotshots
           Redding Smokejumpers
           STF Engines 31, 33
           Whiskeytown Engine 4
           Douglas City Engine 5
           Lewiston Engine 1 and 5
           Water Tender 2

Important Stuff to know

   Performance Pressures
   Climatology that early summer

Community Sensitivities

     Traumatic for community and community members
     Still fresh for community
     Still angry with BLM and sensitive about fire
     Put yourself in their shoes – remember this fire had a severe impact on the community/citizens

BLM Sensitivities

     Traumatic for BLM personnel
     Wrecked careers, harmed reputation, serious impact to relations between agency and community
     BLM people faced serious anger including threats and intimidation
     Trying to re-develop relations with the community
     Did not want Burn Boss involved with the staff ride in any way

Not here to judge people, but to learn from their experience




                                                                                                       9
Preliminary Study Phase - Continued

Additional Information

   Professional Behavior
   Importance of timeliness
   No TDG, Q&A instead
   Would like an AAR of the staff ride by bus, not on lessons learned
   Friday’s Expectations- One thing learned with HRO in mind

Questions?

Sound Logistics?

Field Study Phase: Lowden Ranch Staff Ride

HRO Principle: Preoccupation with Failure

On Burn Day, numerous weak signals of failure were apparent early in the day, including:

   The Burn Boss was scrambling to fill resources due to cancellations of planned resources
   Redding Smokejumpers available to the project dwindled from 11 on first attempt to 3 on Burn Day
   Person assigned to key position (Ignition Specialist) changed on Burn Day
   Key holding resources and the Burn Boss (T) arrived on-site late
   Copies of the Incident Action Plan (IAP) did not arrive in time for the start of the briefing
   When the Burn Boss (T) arrived with the IAPs, they were not collated and were collated as handed-out
   The Burn Plan was not made available to key project personnel
   Briefing conducted without benefit of the Burn Plan. Burn Boss drew key information from memory
   Key project personnel came away without knowing prescription parameters
   On-site weather observations and spot forecast not apparent to key project personnel
   Despite apparent lack of weather observations, mindset was that conditions would remain favorable

                         1/2
    The briefing lasted 1 hours

Stress was a factor, including:

   Resource cancellations and difficulty obtaining replacement resources
   Performance pressure (both agency imposed and self-imposed) – including two previous attempts
   Delayed briefing while resources on-site and waiting
   Burn Boss and Burn Boss (T) appeared to not be completely on the same page re. Burn Plan

Following the briefing, additional weak signals of failure were apparent, including:

 Local fire department engines arrived on site with no compatible radios, were issued field programmed
  handhelds, and given brief instructions (this was the first exposure to these radios for the assigned
  firefighters)

 Prior to the test burn, side conversations had begun about delays and conditions. A small group
  approached the Burn Boss with the intent of suggesting that he abort the day’s burn. One of the people
  involved in that conversation said….

“We were probably pretty weak in our communication that way. We didn’t come right out and say
‘Do you really want to do this?”




                                                                                                      10
Field Study Phase - Continued

The people involved in that conversation observed that the Burn Boss was clearly under performance
pressure, and the burn proceeded as planned. Following a successful test burn around 10:30, personnel
became more confident and their concerns subsided, but weak signals continued to mount:

   Key project personnel were listening to multiple radio channels
   Additional priorities cropped-up after burning began (protecting trees along road and archeological site)
   Efforts to protect trees along road were ineffective from start
   Minimal, unplanned scratchline constructed to control fire’s edge
   Mindset: “I’ve never seen grass spot”
   Availability of holding forces for East flank dependent on controlling spots in Northwest corner of unit

The Ignition Specialist was relatively new to prescribed fire, and was unsure of what signals to pay
attention to (but had misgivings prior to the test burn and had thought several times, during ignition, that
“We need to cut this off.”)

“In my mind’s eye, we probably shouldn’t have burned that day, to tell you the truth.”

Ignition team on East flank sped-up ignition to make up for delays caused by need to construct
scratchline and prep trees along road

Archeological site became a distraction immediately prior to the fire spotting across the scratchline and
then across the road and outside the unit

“You really don’t want to be involved in something like this.”

Fire essentially organized in two halves; like two different operations

Diverse resources and people who did not know each other and who hadn’t worked together presented a
factor

Holding concern was actually across the river and holding engine was deployed there (opposite from
escape)

Holding Boss realized that an engine on-site was staffed with firefighters with no wildland fire experience

“Once we started burning, everything looked good. The ‘just say no’ instinct went away.”

Holding forces were committed to the spot fire in the Northwest corner of the unit when the spots on the
East flank occurred

A locked gate (that project personnel had been told was unlocked) prevented holding forces from
accessing the spot fires, requiring progressive hoselay construction

The engine attacking the key spot fire ran out of water and the spot fires escaped




                                                                                                            11
                                    My Lessons Learned from Lowden Rx
                                       By Robert Holt (Holding Boss)

1. Trust your “gut”; your first instinct is often right about a situation;
      Read “Blink” by Malcolm Gladwell re: “thin-slicing.”

2. Stay on top of your game at all times;
      Casualness leads to catastrophe.

3. When you say “no” to an assignment, do it with conviction;
     Use turndown protocol on pg. 20-21 of IRPG.

4. Disasters are collections of small mistakes;

5. Squirrel nets can be over-used & abused;
     Effective and continuous communication with other resources is the key to success.

6. You’re never as good a firefighter as you think you are;
     “Always be a student of fire”
     Putting a torch to the ground is probably the most critical thing we do as wildland firefighters.

7. Remember that unlike wildland fires, YOU are the ignition source on a prescribed fire;
     YOU can control time frames;
     YOU can modify burn patterns & holding availability;
     YOU can wait until another day!

8. Just because someone has a more impressive title than you doesn’t mean they are a better
   firefighter;
       Trust nobody until you’ve worked with them a few times.

9. When you or your crewmembers are involved in a disaster, make use of Critical Incident Stress
   Debriefings!
     Traumatic stress reactions can be delayed, even by months or years;
     Don’t be a tough guy & say no when a CISD is offered;
     NEVER ridicule someone who requests a CISD.

10. Performance ratings linked to acres treated are an extremely bad idea;
     Waiting until you have a successful burn window might be more cost effective in the long run
      (increasing cost-per-acre vs. Agency paying for property lost from escape).

11. You’re probably lagging behind the fire’s timeline more than you realize;
     Pay attention to your senses and experience; BEHAVE runs are for computers- not for grunts.

12. Be intimately familiar with the prescribed fire area;
     Resource orders filled the day of the burn aren’t a good idea;
     Know what’s adjacent to your perimeter;
     Don’t commence operations until thorough recon has been done.

13. Make sure everyone on the ground is experienced in their roles;
     Volunteer engines are NOT the same as Agency engines, even though they might both be “Type 3
      engines.”




                                                                                                          12
                                Robert Holt Lessons Learned – Continued

14. Pay attention to alignments and other Campbell Prediction System premises;
     Remember that spot forecasts are made miles away from where the fire is – double check the
      weather!

15. DOCUMENT YOUR ACTIONS!
     Use a person as a scribe if necessary;
     Possibly use Voice Recorders.

Breakdowns began before Burn Day. Recalling the weak signals present. It wasn’t one thing, but an
accumulation of things, including:

 Performance pressures (both agency imposed and self-imposed)

 Complacency: A mindset that it was just grass, flat and easy

 Inexperienced engine crew and communication issues with volunteers

 Signal from CDF - We don’t do that, we don’t burn on Fridays and we certainly don’t burn before holiday
  weekends.

 Left scrambling for resources on Burn Day

 No IAP or burn plan at briefing

 No current weather (or at least not briefed to project personnel) – Redding NWS did issue Spot
  Forecast for day

 Key personnel report, ”Everything was looking good right up until the time that the fire spotted.”
  Personnel simplified their interpretations of information in light of performance pressure on the Burn
  Boss (both agency imposed and self-imposed)

 Mindset was fire suppression (vs. holding on a prescribed burn). Mentality among crewmembers was
  waiting, waiting, waiting and certainty that the burn would not happen. People had to re-engage.

    “We all knew it was getting hotter and drier.”

 People were preoccupied, distracted, focused on peripheral issues.

 Situational awareness: Did not have perspective. Focused on fence and one house, or across the river.
  Generally unaware of proximity to Lewiston.

 Missions within the mission became distractions. Not prepared for changing priorities (prevent
  scorching of trees along road, archeological site, etc)




                                                                                                           13
The Aftermath was Staggering

 A very expensive failure ($24.5 million)

 A huge impact on lives, careers and agency reputation

    “Once acceptance has been lost it is very difficult to gain acceptance from the community
    again.”

    “BLM employees were threatened with violence and even death threats.”

    “Every day, the community looks at that scar and thinks about whose fault that was.”

 An enormous impact on the community and individual citizens

    “This community is still a rural community with a long-term memory. The Federal government
    has not proven to the community of Lewiston that they can do the right thing ever since the
    fire started.”

    “People were left without anything, including a change of underwear.”

Resilience: The BLM immediately took responsibility for the fire without hesitation, and a statement of
responsibility and direction for responding to the community came from the highest level of the
organization. State Director was very visible and very accessible to the community. The day after the
fire, the BLM opened a claims center. One of the people who had lost their home worked in the claims
unit to provide a compassionate friend to initially meet with and talk to people.

    “The fact that the agency stood up and took responsibility, in the face of all that, was the right
    thing to do.”

Resilience: BLM – California made significant changes in their prescribed fire policy (significantly ahead
of national changes). More line officer involvement and direction. Improved go/no-go checklist with a
requirement for the signatures of the Holding Boss and Ignition Specialist. Changed approval process
(long and drawn-out) – people complain, but it is the result of a nearly $25 million mistake and years of
pain. Tightened-up the Burn Boss qualification process.

Resilience: Improved public involvement and coordination.

    “There were obvious repercussions against the Burn Boss, but there were repercussions all
    the way up the chain.”

    “There was some discussion earlier about whether there was agency pressure on Doug. I can
    tell you there was. There was a lot. I think our institutional memory on that has run out, and
    we’re doing the same thing again.”

    “It is hard for the community to let go of the past, but there has been a small movement of
    people saying the that the community cannot change what has happened in the past, and
    needs to look at what can be done to change the future. But, with the distrust of the Federal
    government, the town is still in a very fragile mode and any further negative acts by the
    Federal government can disrupt their current healing process.”




                                                                                                          14
Integration Phase: Lowden Ranch Staff Ride

Discussion Outline

Perspective on HRO and Application to Staff ride

Round Robin discussion of staff ride and HRO principles (each participant asked to relate one key
learning point)

Close Out – parallels between Lowden Ranch prescribed burn and prescribed burns that Forest does
now and encouragement to make the five principles of mindfulness part of each person’s personal
performance plan

Key Learning Points

   People cannot (or will not) defer to expertise unless the people with the expertise speak-up

   The expertise is often not at the top of the organization – use the expertise that exists within the
    organization

   Must be preoccupied with failure – relentlessly seek (work to detect) weak signals

   When you are detecting weak signals of failure, you must communicate – must speak-up (regardless
    of your position in the organization)

   Staff ride (and stand presenters) are living examples of resilience

   Do not oversimplify your preoccupation with failure

   Good people make bad mistakes because they are not managing their operation mindfully

   HRO is a mindset, a way of thinking

   People come to the job (operation) already stressed and distracted – makes mindfulness all that more
    important

   Very easy to oversimplify – particularly on a seemingly non-complex operation

   Staff rides help participants recover from critical incidents (commitment to resilience)

   BLM did right thing by immediately taking responsibility (commitment to resilience)

   Performance pressure sets people up for failure (need to contain it)

   We are still operating from a paradigm that the person in charge, the person with the responsibility
    has the expertise

   We need to learn from our mistakes – we’ve got to talk about them

   Attitudes and expectations (we’re not going to burn today) turn into blind spots

   Sensitivity to operations includes doing your homework – making sure the preparation work is done

   The plan (and a focus on plans) can be the enemy of sensitivity to operations




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Key Learning Points – Continued

 The world can turn upside down on you very quickly – preoccupy yourself with failure – look for weak
  signals relentlessly and respond to them strongly

 Preoccupation with failure has a lot to do with perceptions – perceptions vary by rank/position in the
  organization. At the firefighter level, failure may mean the pump not starting. At the FMO/Line officer
  level not meeting a target may constitute failure. The principle applies at every level.

 Situational awareness and sensitivity to operations – people would have been more mindful had they
  been aware of the burn unit’s proximity to Lewiston

 Preoccupation with failure is a mindset – constantly ask “What if?”

 Being in your comfort zone can be a trap and blind spot. “Can-do” can be a blind spot.

 Stuff happens (despite our best efforts). Therefore, we must develop a resilient organization that can
  contain human error and recover from it.

 Sense of urgency is a weak signal of failure itself, an enemy of sensitivity to operations, may keep
  you from deferring to expertise and encourages over-simplification in the interest of time




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Recommendations

The following recommendations from the workshop’s facilitator are intended to help the Klamath National
Forest continue to improve its already successful efforts. They are also intended to reflect the after action
reviews and workshop evaluations that follow.

1. Continue the practice of holding an annual all-hands workshop. As reported elsewhere in this report,
   considering the diversity of the target audience (GS-3 Apprentice Firefighters to the Forest
   Supervisor), the organizers would expect difficulty in pleasing everyone. However, despite the
   diverse group and other challenges, 93% of participants felt that the workshop met or exceeded the
   stated goals and objectives. Five percent took a “wait and see” attitude. Overall, the workshop
   appears to be a worthy use of the Forest’s human and financial resources.

2. Consider shortening the workshop to three or four days. While the workshop is of value and an
   effective use of resources, it also represents a considerable commitment at a busy time of year. The
   ability to shorten the length requires careful consideration of intent, content, and staff ride logistics.

3. Consider whether the organizers’ expectations for the first goal of the workshop (“Continue
   developing a Forest team that understands and respects the roles and responsibilities in wildfire
   management”) are completely realistic. Some organizers feel the workshop fell short on this goal,
   and that they missed non-fire people from the Forest, especially line officers. Some felt that the
   purpose and intent of the workshop was not adequately communicated to the Forest Leadership
   Team and non-fire personnel, having left invitation of non-fire personnel from the Supervisor’s Office
   up to their staff officer. However, one must ask whether it is reasonable to expect that key personnel
   from other programs can invest a full week of their time in a fire and aviation management activity.
   Re-evaluate expectations and consider alternatives to meeting this goal, such as inviting non-fire
   personnel to a specific portion of the workshop for a specific purpose.

4. Continue using staff rides as a learning tool and component of the workshop. It appears that the
   target audience appreciates and benefits from this valuable learning method. If possible, consider
   conducting staff rides closer to home, so that they involve less travel.

5. Continue to work on travel and lodging arrangements to make them as efficient and satisfying to
   participants as practical (single payer for lodging; integrating bus, rooms, roommates, groups, etc;
   reserving blocks of rooms; etc.) See specific comments in the AAR and evaluation notes.

6. Strive to provide participants with as much information as possible as far in advance as possible,
   including:

       Having the final agenda out to participants sooner
       Briefing travel plans well in advance
       Making room/roommate assignments known
       Involving participants on plans for Division meeting/meal and advising them in advance of plan
       Reviewing objectives throughout week
       Getting the workshop evaluation form out well in advance

7. Brief people on phased concept of a staff ride. People seemed confused about the integration phase
   (a critically important part) of the staff ride on Friday. Make sure people understand the phasing
   concept and know what to expect by briefing people on this aspect and reinforcing the concept at key
   opportunities.




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Recommendations - Continued

8. Systematically and comprehensively review the Klamath National Forest Fire and Aviation
   Management program’s commitment to, and plans for HRO. Once done, plan for purposefully and
   systematically implementing the Forest’s desires. If the KNF Fire and Aviation Management program
   remains committed to making HRO operational, don’t abandon your high reliability organizing (HRO)
   training initiative. While there are those who fear that the Klamath National Forest has
   overemphasized HRO and that the workshop participants have now “been there and done that” it
   appears that most Klamath National Forest Fire and Aviation Management personnel are now at the
   “awareness” stage. The KNF may consider migrating HRO training to a more hands-on and
   participatory model. Alternatives include, more diligently and systematically incorporating HRO
   principles into staff rides, and employing both sand table exercises (STEX) and tactical decision-
   making games (TDG) that integrate HRO principles.

9. Review the AARs and the workshop evaluation information that follows for detailed information on
   workshop success, performance and areas needing improvement.




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AAR: Lowden Ranch Staff Ride

Sustain

    Continue to stagger busses for hotels and staff ride (3)
    Rx burn was a good HRO example
    Lunches were good
    Excellent Staff Ride/Eye opening
    Focus on importance of communication at all levels
    Cohesion as a group (bus group)
    Logistics/logistics team – worked great
    Hotel list was good with names of personnel staying together
    Worked well utilizing hotels right next door to each other
    Shorter bus ride this year
    Dinner wasn’t like a meeting
    Making reservations for dinner to have a nice place for everyone
    Cohesion from all districts
    Having a tour planned for the later buses
    Having all the stand presenters in our group

Improve

  Government credit cards: Either have rooms pre-paid by one person or have roommates on same
   bus. Would be nice to have at least one person per room have a govt. credit card (2)

  Use blocks of rooms to facilitate check-in (2)

  Fiscal responsibility to have roommates for all individuals

  Better busses (3)

  Mix up bus rotation – example, have bus 5 leave first from Yreka and last for the staff ride the
   following day

  Have two buses leave at a time in route to motel

  Have staff ride IAP and roommates prior to All Hands Week

  Vote on dinner location (3)

  More preliminary information (copy of burn plan)

  Some people want to be able to pick their roommate

  Brief travel plans to everyone day before so people can make travel plans to and from districts

  Have buses available at motels to travel to a selected eating place

  Bus together / room together / on same bus




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Staff AAR: All Hands Meeting – Leadership and Mindfulness

What Did We Set Out to Do?

   Reference Workshop Goals and Objectives

What Actually Happened?

   Did successfully help unify leadership by the end of the week

   Proof of success will lie in the evaluation forms from participants

   Fell short on first goal – missed non-fire people including/especially line officers. Forest leadership
    team under-represented. Did achieve this goal for those who did attend.

   Did enhance communication and improve cohesion

Why Did It Happen?

   The purpose and intent of the workshop was not adequately communicated to the Forest leadership
    team and non-fire personnel. Left invitation of non-fire personnel from Supervisor’s Office up to their
    staff officer. In the future, need to proactively answer the question “What’s in it for me?” Because it is
    fire oriented, it does not immediately appear relevant to non-fire personnel.

   The planning/organizing group remained flexible and adaptable

   Excellent work by Logistics team

   Going out and finding the “real players” for staff ride stand presenters

What Will We Do In the Future (Sustain/Improve)?

Sustain: Remembering the delays for staff ride busses #4 and #5 and giving them something to do (tour
of SMJ Base)

Sustain: Dinners that are not like a meeting

Sustain: SMJ Base tour (vs. sleeping in)

Sustain: Staff ride

Sustain: Continue to stagger staff ride busses

Sustain: Outside facilitator. Important and the outside perspective helps

Sustain: Planning team approach and involving contractor in the planning

Sustain: Planning team conference calls

Improve: Shorten (one way to do so would be to try to conduct staff rides more nearby)

Improve: Don’t start-off week/workshop with bad news (recruitment/retention) particularly bad news that
had already been addressed at home units

Improve: Time to move away from formal HRO training (continue to infuse, but not provide formal training)




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Staff AAR - Continued

Improve: Facilitator take-care when attempting humor with an unfamiliar group

Improve: Consider non-fire staff ride?

Improve: Integrate hotel and bus manifests/Integrate groups, busses and hotels

Improve: Reserve blocks of motel rooms

Improve: Allow people to vote on Division dinner locations

Improve: Brief travel plans better

Improve: Use more “junior” people as bus/group leaders as a developmental opportunity

Improve: Be more clear and specific when briefing bus/group leader duties

Improve: Reverse busses so that first bus to destination is not also the first bus home (spread benefits
around)

Improve: Arrange a single payer for the motel rooms

Improve: Motel check-in process

Improve: Not everyone liked the SMJ Base tour (would have preferred to sleep in)

Improve: Think about how to get logistics people the opportunity to participate in the staff ride (with
planning, this can be fixed by alternating)




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Participant Evaluations: All Hands Meeting – Leadership and Mindfulness

1. Were the workshop goals and objectives met?

    Yes or equivalent (17)
    Overall, yes. It’s a work in process. Hope it continues. It’s money well spent in our future.
    Very much so, at least with my group. Building leadership and improving communication is and will be
     something we need to always work on. I feel this week helped us to improve.
    Yes, I had rough idea of HRO, have a better understanding now, and still have a way to go.
    Yes, even exceeded. The objectives need to be reviewed through the week.
    Yes, for me it pulled all together with applying the five principles, Gave a good understanding of how a leader just
     doesn’t become a leader a constant commitment to resilience.
    Yes, on all fronts.
    Absolutely!
    Yes, to differing degrees. I think that it will still take time to build leadership capacity.
    Yes, they were met.
    Goals-Yes, by getting the folks together from the different levels and giving us the opportunity to meet, get to know
     each other and how they feel and think about the forest organization and management. Objectives-For me, the
     concept of (HRO) was new to me. I am still not sure that I completely grasp the concept but will seriously work on it.
    Yes, except I think some other things like exercises could be implemented to enhance group cohesion and
     communication.
    Yes, the staff ride enforces the HRO principles. All levels of the organization need to be on the same page.
    I believe the goals and objectives were met.
    Yes, I think it was good and I am still not sure about HRO but it was a good week.
    Yes, I believe the goals and objectives were met.
    I think so.
    Yes, I believe they were met, yet I also feel some subjects were pressed and forced too much.
    Yes they were. They helped me out with understanding the situation better and helped me through the whole thing.
    Of course, I felt very involved throughout the entire (HRO) speeches and staff ride!
    Yes, we try to learn and improve from previous mistakes.
    For the most part, yes.
    I believe they were met.
    Yes, very well done for the first time.
    Yes, very much so.
    I won’t know until I see it being used this spring and summer. Hopefully, it should have made some slides.
    Partially. The workshop is a beginning to achieving the goals and objectives. We need to incorporate this in to
     our cultural values more than just at a yearly workshop.

2. What about this workshop was most valuable to you?

    All the perceptions that were brought forward.
    The opportunity to reflect and listen to the other thoughts, process for myself the concepts and
       “lessons learned” that were presented.
    Being able to put myself in someone else’s shoes without having to feel all the pain.
    The staff ride and the speakers and their stories about HRO.
    Retention issues. Why I joined the USFS.
    Speak up your gut feeling. Sh__ happens.
    The staff ride. The value in the staff ride was due to the presenters. Having the people who lived
     through this made each piece more valuable.
    Riva’s presentation on the Cascade II burn and her integration of HRO.
    Two things. 1. Getting together with all the personnel on the forest to get acquainted and time to
     talk. 2. Staff ride was a great slide creator. You can’t have too many slides.
    The staff ride (3)
    To learn.




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2. What about this workshop was most valuable to you? – Continued

   The staff ride with personal interaction among all the players.
   Just starting to develop strengths in the HRO method of learning.
   The staff ride with people who could tell me what really happened help me a lot.
   Good information. Good speakers. I liked hearing from North OPS. Met some people on the forest I
    hadn’t met. Lessons learned.
   The staff ride was what I valued the most.
   Sharing of experiences of how we incorporate HRO in our daily work. The field day to Lewiston was
    very enlightening.
   The staff ride provided more hands on experience.
   Learning what happened in the past. So that I can lean from their mistakes.
   The examples of HRO and mindfulness in operations and the staff ride. Getting everyone’s input
    during the integration phase. The critical stress process and difference between grew counseling.
   The workshop was valuable in the respect that we can learn from other’s mistakes and have the people that were
    there actually tell you how they messed up and how they could have fixed it.
   Definitely the staff ride, as a new manager I need to be aware of the tripping points or small things that maybe
    warning signs of potential problems. To listen to the folks I supervise, as to me they are the experts.
   How I incorporate the HRO principles. How I work and how I can improve.
   The staff walk itself.
   Communicating thoughts and feeling about a situation and listening to what is being said. Then
    applying it to the situation.
   The personal experiences from folks from the forest and the staff ride.
   The professional way in that it was conducted. The comfort of the facility, the presenters’ professional
    expertise. Lastly, the content was excellent to implement leadership.
   Stand #5 of the staff ride. Joe Miller’s presentation. Riva’s presentation. Happy Camp helicopter
    presentation.
   Getting to know members of the fire organization better in a relaxed setting Wednesday night.
   All HROs five principles and now I will apply and use these five principles in and out of fire.
   The open forum for sharing and receiving throughout the week. Great feedback!
   To see how easy it is to get sucked into situations and to very experienced folks. How I can apply or
    use HRO principles in my every day life.
   How the principles apply in real life situations (case studies, staff ride)
   The staff ride, everyone talking together.
   Sorry, I was not there.
   Learning, there were so many things I picked up from all the presentations to the staff ride.
   The staff ride was a great learning tool.
   Having the actual people on site to talk with.
   Understanding that it could happen to anyone and it is always around the little thing that gets you.
   Staff ride, having the people actually involved in the operations really helped.
   The staff ride, actually being at the place where the incident happened.
   The staff ride and hearing the stories from various speakers about their experiences from other fires.




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3. What about this workshop was least valuable to you?

   HRO presentation at time felt like beating a dead horse. Three days was a bit long.
   Round robin (note: probably reference to integration phase of staff ride.)
   Opening day.
   Joe Millar’s presentation didn’t really give me much.
   HRO. I’m not sure I’m on board with HRO. I still think it’s the same stuff we have been saying for years, just in
    different terminology.
   Putting people on the spot. Making them get up and talk. Example the last day. People who want to talk let them
    talk. Give us the choice. One and half hours of people talking, it starts to sound like blah, blah, blah, lost interest
    (note: reference to integration phase of staff ride).
   I can’t think of any thing. I think it was all valuable.
   The length of lecture time was not valuable. I believe it could be all hands half week. Some of the presentations
    appeared to be solely used for the purpose of filling the day.
   All presentations were valuable but in varying degrees. I think the least helpful was “practical” examples from the
    group. To me they were just war stories.
   The HRO concept is a little complicated. Big words could be made a little simpler.
   I felt it was lengthy, although I benefited from it.
   Everything had some value.
   The BBQ, but I would keep it anyway.
   Discussion about retention.
   Naming people without at least some kind of visual picture that folks can relate to (note: reference to staff ride
    field study phase?).
   It (workshop) was too long. I had difficult time maintaining enthusiasm throughout the week.
   I don’t think that there was anything not valuable. I do think it is a long week and a lot of information coming at us.
    After day three I’m pretty tapped out. Maybe a short week?
   The beginning of the workshop was kind of negative with hiring and retention; we have this stuff already packed
    away in our minds. In my own mind I have given positive attributes and moved forward.
   Being tattled on by the facilitator to my forest FMO instead of him coming directly to me.
   I really do not have a least.
   The division dinner on Wednesday. The first four stands of the ride. The AAR on Friday. AARs with a group this big
    are pointless After the first ten people say the same thing in a slightly different way, everyone falls asleep. Plus it’s
    Friday and for many, our usual day off. Thus, half of us are checked out before it even begins (Note: not an AAR,
    actually a reference to the integration of the staff ride).
   It all had tangible value at some level.
   The bus-ride, although it was ok because we were a great group.
   No need for 1 ½ hour cookout first day.
   Not applicable.
   The mode of transportation to the staff ride. To witness the eagerness of people to consume mind-altering
    liquids. I preferred to be in an alternate environment.
   Some of the retention talks. It’s never going to change.
   Downtime.
   Riding the bus!
   The amount of time it took.
   That it takes up a whole week, I can see several opportunities where condensing it down to two or three
    days could be possible and combining partial day Monday and partial day Friday. Part of my comment
    stems from what I heard before the staff ride. Spending so much time traveling to Redding-why not use
    crew buggies verses buses.
   I took something away from each day.




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What about this workshop was least valuable to you? - Continued

 Sorry, was not there.
 Well just talking with a lot of the folks, I gathered that most people could not tell me the definition of the
  words used to describe “HRO”. Also, a big thing I hear over and over is to keep things simple. I believe the
  HROs are failing to keep it simple. On a better note the stories and experiences told on the staff ride really
  opened my eyes to important details one should know while fighting fire.
 I don’t think anything was invaluable. I took something away from everything that went on this week.
 News from North OPS.
 The CSID session. Not that it wasn’t worthwhile but it was of least value to me this week.
 Was a little scared to get sniped white in Lewiston.
 Nothing, I learned a lot and I’ll take everything I learned on the events of the week with me this upcoming
  season.

4. What should we do next time?

Sustain

 It was great having the people that were on-site then on-site this week.
 Keep the interest up.
 Continue using community theater. Revisit HRO. Bring Mike back. Another staff ride, Coordination
  was great.
 Time spent together to open up communication among forest resources. Bring knowledgeable or
  relevant speakers. The lessons learned presentations were very valuable. Re: Cascade II, Elk
  complex, Heli, etc.
 Abstain. I think it is time to skip a year. If we do something each year, camp out, least expense as
  possible.
 Staff rides, the Rx fire angle was refreshing. Stanza would be good next year. There are once again
  real people to be involved that were there.
 Staff ride (2)
 Short drive times to staff rides (Redding nice and close). Personal stories.
 Community theater.
 This was a great staff ride. Anyone who wants to be an RxB or is currently one needs to go and
  participate. It could change their mind.
 The value of learning from a staff ride.
 AARs
 Keep those that actually participated.
 Having all stay at a location away from home for teambuilding.
 Keep the classroom portion. Keep some kind of staff ride.
 Cascade II was dialed and relevant! Thanks!
 The whole thing i.e. presentations, presenters, staff ride and presenters, etc.
 Round robin on what we got out of the week (reference to integration phase of staff ride?). Enough water
  and toilets (great job logistics). Invite all. Good mix on buses and I didn’t hear complaints on roommates.
 Continue the leadership skills, tools and learning lessons. Have this event every year.
 Logistics – liked the use of the community theater. Operations- staff ride was really great! Actual folks
  involved with the Rx burn. I think their presence and input was invaluable!
 Case Studies. Staff ride.
 Strive to excellence. Stress to the new, inexperienced employees to learn and be all you can be as
  a leadership.
 Johnny Clem’s stand #5.
 All of it was useful.
 The crew/forest cohesion. Last day what we learned. Lessons learned.
 Keep the workshop. Maybe examine a new tool or set of principles next time.




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Sustain - Continued

 Staff ride and examples from others experience. Mike DeGrosky’s involvement as is important, not
  only because he’s a subject matter expert, but because he’s brought in from outside the Klamath.
  He made it more formal.
 Keep doing staff rides.
 Stay in the field (staff ride)
 Pretty much everything was the way I expected it.
 Everything went well except the hotel situations!
 Keep it with the people who were on the bus.
 Put us in the tactical position. Give us a map, resources and time frame and ask what are our
  concerns and how will you organize your tactics and concerns.
 If we can’t do another staff ride, consider STEX or TDGS for a day to keep the interaction and
  thoughtful consideration of increasing our awareness.
 It is good to expose folks to all levels of the process. It’s easy to focus on aviation and crew
  examples but RX fire and engine crews also have some things to share.

Improve

 There was a lot of re-cap – but I understand why.
 Shorten week.
 Attempt to have more members of the forest to attend. Inform us when BLM has changed their
  mind about allowing Doug to participate.
 Less time.
 Being last bus #5, everything was stall tactics. Made it for a long, long drawn out day. Vs. bus / fast pace. The
  first day people had questions about hiring of people getting positions that are not qualified with Riva and Patty.
  The question never really got answered just pushed off to next question. Have the balls and answer it. Tell it is
  how it is. Another thing was brought up first day by Riva was about hiring Demo/Merit. Riva’s quote “you only do
  one, you’re lazy” strong statement, which is bull____. This never got answered either about do you have to fill
  out both or just one. These questions never got answered just brushed off like always.
 I love this process but wonder if we could alternate some longer events with shorter ones i.e. staff ride one year,
  then other forms of training in a shorter format or incorporate stuff our military dispatchers in. I think about
  processes like L-380381 or exposing forest leadership to one of those classes. I understand MCS does a class
  for IDT.
 Logistics communication was a bit bumpy for our bus. Entered staff ride from wrong side came in an hour early
  today.
 The coordinator, we were always on a time line. Would like to see us coordinate it on our own. Find
  a new topic other than HRO.
 The week went well but I think that Monday could have started at 1300. Full day the half day and lunch then
  head down to the event. Lot of wasted time on Wednesday.
 Logistics-same buses for roommates. Have information day before to arrange rides.
 HRO is great but I think if we could do more on active communication and leadership that would be
  awesome. Also, logistics could be better. Keep roommates on the same bus and let them know ahead of
  time so that rides could be coordinated.
 Get Doug (Bus boss) involved. I would like to see it from his opinion. Maybe mix in some public from
  Lewiston to get their views, feelings and opinions.
 Block rooms rather than assigned in case of cancellation. Less closing remarks.
 Give this form to people the night before.
 Hotel room reservation. Reserve blocks of rooms.
 Having people read the whole investigative report, so they have more information.




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Improve – Continued

    Logistics-sure, mix us up on the buses but please take into consideration driving time to our home units. Also,
     0800 means down river districts had to wake up at 0540 to get here on time. Also, to contain costs have everyone
     share hotel rooms, there were a lot of single rooms.
    I understand mixing people up on the bus and improving crew cohesion however, a lot of people
     live a ways away and waiting three or four hours is not too big of a deal, but is it necessary?
    Logistics. As far as room assignments and bus assignments.
    Not stay the night. Save some money.
    Buses! Tour buses would be nice. Cost is an issue. Consider doing this every two or three years?
     (Avoidance of “mandatory meeting) looses value and interest of personnel if forced every year.
    I would have liked Doug to be there. If Doug had been there effectiveness would have been much greater.
    I feel the whole week was very positive, and at this time I cannot add anything. Maybe schedule something,
     more tours to kill time prior to departing for the field visit in the morning.
    Since we’ve all had pretty good exposure to HRO and the principles, maybe we just need a reading book or
     handout to get us in the mode and just to shorten the time commitment. Although the auditorium was a nice
     location, I felt like it was too big, which influenced group dynamics, it was intimidating. The room at the
     fairgrounds was better because we were all sitting together, not spread out. And being closer together in a
     smaller area made it much easier to speak up, it felt more intimate.
    Shorten the overall length of the course to three to four days instead of a week. Combine this with both
     permanent and seasonal fire refreshers a one shot one kill type deal covering all fire employees.
    Please try to fit a three-day workshop and the fire refresher into one week. We could have accomplished all
     that we did in five days this week in three days. We could have done a full day on the first day and had
     lecture for half day the day we traveled. I believe this was important and valuable but please try to maximize
     time efficiency. Also bring a new topic every year.
    Include more from those who were involved.
    Don’t just do a staff ride to do a staff. Look for a very meaningful purpose. Possibly staff ride, a success starts, a
     situation where mindfulness was at the forefront.
    Start the meeting out with powerful information or exercises and nothing else!
    I didn’t like having to come in at 8 am on Wednesday for an hour or so and then have to wait around half a day
     for buses. Maybe start later on Wednesday, if not needing to leave until later. Do the logistics the day before.
    Logistics-that is we had lots of downtime waiting for buses, etc. It seems that we could use that time better.
     Expedition buses- maybe there is a better way to transport folks? Operations- the facilitator was somewhat
     annoying by the end of the week.
    Bus ride-roommates together. Organized faster to give out all info sooner.
    Put hotel roommates on the same bus to avoid delays with check in. A lot of time, effort, and money went into
     the staff ride and all we did was walk around a field for a couple of hours. Was it really worth it? We could have
     covered the same principles in the classroom. The Happy/Oak division dinner. $25 a plate? We’re not all GS-
     11’s here. Why couldn’t we have eaten at a normal restaurant like the other divisions? Some folks didn’t eat
     because of the expense. Drop the AAR.
    Reduce from five days to three or four days; compress. Make sure you have “fire” covered back at
     the home units. Have a contingency plan.
    The first lecture on the principles was sufficient. The addition of case studies and how they apply were helpful in
     solidifying the concept. The final lecture on the principles was over-kill. The start time should be moved ahead
     to 9:00 for people with a long commute. The hours can be made up throughout the week. Long days with a long
     commute make people less likely to absorb information due to fatigue. (Also, “fiscal responsibility”)




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Improve – Continued

1.Encourage other stand hosts to develop a “Lessons Learned”. Akin to R- Holts. 2. In stand “5” have the
“BLM’ers” (Paul, et al.) speak earlier so as to establish a basic trust level with group. Our people may have
been intimidated being “surrounded” by folks wearing brown shirts and dark glasses. This may have reduced
participation in the Question and answer comment session. 3. Open it to other shops so we can better
appreciate other roles and build on the concept of “mutual purpose”. 4. Pair-up roommates on buses (minor
detail)(logistically).

Focus more on good decisions or outcomes although I think we learn more by bad examples. No
matter your status, assign roommates that can be together.




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