Friday, July 31, 2015

Risk, Gain and Loss: What are We Willing to Accept?

1st Minnesota Infantry Regiment Monument at the Gettysburg Battlefield
(Photo credit: Wikipedia)
By Curtis Heaton

“Are you sure we do not have acceptable losses in wildland fire?" I quietly asked.

The group shifted around uncomfortably waiting for someone to speak. It was a beautiful fall day. I was facilitating an L-580 Gettysburg Staff Ride conference group under the shadow of the 1st Minnesota Monument.

The theme at the stand was Leadership and Risk. One of my fire peers had just passionately stated: “We are not the military and we do not have acceptable losses.” The location was fitting. The 1st Minnesota Volunteers had incurred an 82 percent causality rate in just five minutes of pitched fighting. It is one of the greatest single engagement losses in the history of the U.S. military. We were standing at the very spot where they received the order to attack.

Once again, I asked: “Do we have acceptable losses in wildland fire?” I could sense that critical thinking and group sense-making was beginning to occur.

By Painting by Don Troiani. Courtesy of The National Guard [CC BY 2.0 (http://creativecommons.org/licenses/by/2.0)], via Wikimedia Commons
By Painting by Don Troiani. Courtesy of The National Guard [CC BY 2.0 (http://creativecommons.org/licenses/by/2.0)], via Wikimedia Commons
The 1st Minnesota Stand
On the afternoon of July 2, 1863 Confederate forces launched a major offensive aimed at defeating the Union forces positioned outside of Gettysburg. As the battle raged, Union Major General Winfield Scott Hancock sensed the Union plan was failing and the Confederates were poised to break through his thinly held lines. A breach meant the Union army would be divided and crushed. Hancock needed time to shift resources. He turned to the only resource he had available, the 1st Minnesota Volunteers.

Hancock ordered the 1st Minnesota Regiment to: “Take those colors!” Outnumbered 6 to 1, both Hancock and the brave Minnesotans knew they were wading into a conflagration. This risk was the only option Hancock had in his arsenal. His time wedge had closed. He had no room to maneuver—no margin.

Events beyond his control had placed him on Cemetery Ridge—the center of the Union defense. Decisions made by his leaders and the actions of others had placed him at the crucial part of the battlefield.

They Followed the Plan . . .
The 1st Minnesota had simply filled a resource order that morning. They followed the plan and arrived at their drop point and now they were staring at a wall of Confederates. Both the threat and consequences were clear. They had to stop the rebels, a force of 1,500 crack troops. A total of 262 Minnesotans engaged. Five minutes later 47 Minnesotans were left standing. The actions of 1st Minnesota disrupted the Confederate offensive and bought Hancock time to move up Union reinforcements. The Union line held that day.

From a General’s perspective, the risk of losing an entire regiment was worth the gain of saving the Union line. But what about the Private? Why would the Minnesotans willingly accept so much risk? Are we any different? How can we learn from their sacrifice? (Brothers of War website)

Why Gettysburg?
The Battle of Gettysburg was arguably the key battle in the Civil War. Two great armies collided at a crossroads and fought for three days—incurring tens of thousands of casualties. It is considered “the high water mark of the Confederacy” and may have decided the outcome of the Civil War and the fate of a nation. It is the most studied incident in American history.

For all of these reasons and more, the Battle of Gettysburg is a great place to study leadership and decision-making.

How We View Risk in Wildland Fire
While “Risk” comes up at various points during the Gettysburg Staff Ride, it always reaches passionate debate at the 1st Minnesota Monument.

I consistently hear my peers dismiss lessons from the military because “We do not have acceptable losses in wildland fire.” “They make decisions differently.

I disagree.

There have been more than 500 wildland firefighters killed in the line-of-duty during my career alone—roughly 20 per year. We lose billions of dollars in capital and resources, we experience a number of serious injuries, as well as both physical and emotional trauma, and much more. This is what our current system produces—the loss we “accept”. We also protect many things: life, property, resources, infrastructure. But nothing is ever free in the risk equation.

The uncomfortable discussion about risk, gain, and loss only seems to occur when the Staff Ride participants begin to realize their decisions and actions as leaders can result in the loss of life. When it becomes personal.

Many have never experienced a really bad day (and, fortunately, most never will). But as an occupation, wildland fire is deadly and destructive. It is also a beautiful, simple, and necessary act of nature. And as leaders within that occupation, we need to be honest about the consequences of our decisions and the human factors that influence them. We need to be honest how words and behaviors reflect our personal view of risk. Language

Do we normalize risk by simply avoiding the topic? Verbs for discussing risk have become nouns in our language. In essence we “normalize” the action. Our words and processes make risk acceptable. We have developed a script in order to avoid the uncomfortable discussion about risk and loss. We accept that risk is in everything we do, yet culturally we continue to talk about risk in an ancillary fashion to the actual decision-making.

Initial Attack: we attack wildfires. Hancock ordered 1st Minnesota to attack. Attack is defined as a “violent or harmful act.” Is that what we always want to achieve? Hancock sure did. We build a plan rather than engage in planning. “WFDSS” was designed to encourage critical thinking—it is now a product that we have to develop. Objectives like “Protect _______” is a common objective on an incident. This objective is built on the assumption we can protect anything and that the risk is always worth the gain.

What is the cost to our people for protecting? “Keep the fire north of______, south of_______”. The Box. This common strategy statement assumes all of the hazards found within the box can be mitigated and the exposure justifies the gain. When it fails, we just draw a bigger box. Hancock could not draw a bigger box. He was at the edge of margin. Strategy should be based on time, space, and assets. A strong strategy encourages maneuverability and flexibility. It creates more margin, rather than reduce it.

Processes

Processes are built into the system to decide, act, and then mitigate risk.

That sequence seems flawed. Sense-making has given way to documenting. We seem to believe we can mitigate everything—just make sure you document it. Fifty or so pages into the Incident Response Pocket Guide (IRPG) addresses some type of hazard mitigation. “See the safety message on p. 17 in your IAP and reference p. 24 in your IRPG on dealing with those downed power lines and be safe!”

The 5-Step Risk Management Process in the IRPG was designed as a critical thinking/analytical tool to support and mirror the decision-making process. Is that how it’s being used? Or do we make a decision and use the tool as a subjective filter to justify a predetermined course of action—and to be comfortable with the risk we have transferred?

We have a page in the IRPG dedicated to “How to properly refuse risk”. Risk has to be properly refused? Risk should always be evaluated and discussed. “Refusing” should be thrown out of our vocabulary. The very stigma associated with this term creates unnecessary friction in the system.

A little friction in the system is good, it encourages us to run a diagnostic, to understand why there is friction. However, if we generate too much friction then the system erodes from within. It destroys itself. We should view every discussion about risk as sense-making, a tactical pause, inquiry—put any label you want on it. But encourage all discussions about risk. The system has enough friction in it as is, we need not create more.

Scripts

Perhaps we have developed a “script” that we are all too comfortable using. You have heard it countless times. It goes like this: “Critical fire weather today…extreme fire behavior…don’t let your guard down…maintain situational awareness…show a lunch break…

It is a well-used script. It has defined a culture. Follow the rules and everything will be okay. Just make sure you document everything in case things do go bad. Did the 1st Minnesota get a safety briefing before they attacked?

We act this way because we are human. Humans are creatures of habit; we love patterns. They make us comfortable. We do it this way because we have always done it this way. When facing uncertainty, humans often revert to fear or quickly dismiss uncertainty so we feel we understand what is occurring. We feel like we are in control. We can feel normal.

Sense-making requires effort. Recognizing how we are influenced by these scripts is the basis for critical thinking—thinking about how we think. Fire has no script. It behaves solely on the conditions. Hancock had no script at Gettysburg. But he clearly understood the conditions and the risk—as did his Minnesotans.

Scripts can be good. Like incident organizers and prescribed fire burn plans that help us to make sense of policies and aid in training and development. Hands down, the wildland fire community is full of outstanding problem solvers. Day in and day out we are constantly adapting plans, tactics, and modifying those scripts to fit reality. We unfold the map on the hood of the truck at DP7 and pause to make sense; to understand. Here we rewrite the script based on our observations, perceptions, and conditions. Here we engage in group sense-making.

Scripts and adaptability are strengths in our culture. And yet they also affect our ability to perceive and detect anomalies and how we communicate deviances. The danger surfaces when the script replaces critical thinking and sense-making. When the script becomes thought.

Sense-Making and Critical Thinking

Hancock and the Minnesotans had little time for group sense-making on July 2, 1863. The Confederates, led by the legendary Robert E. Lee, were pushing hard for the Union line.

Robert E. Lee was the best. He was both feared and respected. I think of Robert E. Lee as a Haines 6 coupled with high winds and record drought. General Lee was extreme fire behavior in 1863. The Confederates were a 30,000-foot convection column ready to collapse on top of Hancock and the Minnesotans.

Hancock had to make sense of what was occurring and he had to think critically. He was not only trying to predict the future but he also needed to share his vision with the 1st Minnesota. He accomplished this solely through his presence and character. He had no process to fall back on or script to reference.

Hancock clearly understood what was at risk strategically. The price for losing the battle would be high. He knew what was at stake—his country. He was a smart guy and understood the politics. He also had a pretty good idea what Robert E. Lee was trying to do. He had learned after getting pummeled by Bobby and the Confederates time and time again. Hancock was preparing to apply those lessons learned at the expense of the 1st Minnesota.

He knew what he was asking the 1st Minnesota to do. He did it out of duty, not personal glory or ego, or by following a process or a script. He made sense of the situation and he communicated the risk.

OK, cool story Heaton, so what’s your point?

My point here is that Hancock, like all great leaders, understood risk and did not avoid it or bury it in ambiguity and false mitigations. He had no qualms about transferring risk; that was his job. He had no issues communicating the risk. His intent was clear and he was clearly accountable for his decision. That is the first lesson on risk from the 1st Minnesota stand.

The second lesson is why the 1st Minnesota accepted the risk from Hancock. They merely filled a resource order and reported to their assigned drop point. Their Branch Director ordered them to attack. They could have attempted to mitigate the risk, transfer the risk, or just declined it and ran away like so many other brave but scared kids that day. But no, they went all in. Why? Why would 262 men march to certain death? Why would firefighters ever leave a safety zone?

Cannon at Gettysburg Battlefield
(Photo credit: Chris Wilcox)
Why We Live and Die Together. What It Means to be ‘Us’.

Why did the 1st Minnesota attack?

As the U.S. Marine SME for my conference group at the Gettysburg Staff Ride always points out: “They didn’t do it for Hancock. They were brothers. One goes, they all go.” The Private at Gettysburg did not fight for a cause. They fought for each other. Their greatest risk was failing their brother. This insight is coming from a veteran (the Marine SME) who understands risk and human performance under stress.

Is our model really any different? We transfer the risk by inserting the operator into a hazardous and uncertain environment and then seem surprised when a group of them die?

So Who are We?

Causes are great: mission, duty, protecting the public and our natural resources. Great stuff and it all has meaning. It is all worth some level of risk. I am in no way downplaying the dedication of our people. But like the 1st Minnesota, we in wildland fire ultimately fight for each other, for our families.

This is the essence of the warrior culture. That sense of being—of belonging to something bigger and better than yourself. Finding your limits and giving it all you have. It is cool.

If you have not been part of what I am describing, then you might not understand. Live side-by-side with someone for months at a time. Share hardships. Laugh, sweat, bleed and cry with them and you do not (will not) fail them.

You will risk a lot for each other. You will do things with them you would never do alone. Ask a career Hotshot or Smokejumper or Helitack or Engine Captain what is most important to them. The answer is their people. I am honored to be associated with the wildland fire community and equally humbled by what that actually means. Being part of this special group influences my decisions, it defines my behavior at times and it may inadvertently encourage me to act in certain ways. Call it trust or duty or even ego.

It is complicated enough that I am not sure I even understand it. Our Fallen may not have died for a glorious cause but we can choose to honor them for the gift they left behind; the gift of knowledge. We can choose to learn from their sacrifice. It is a priceless gift and not one to be taken lightly.

We Need to Be Real About Accepting Risk

This esprit de corps is not something that we should try to “fix”. Rather, it needs to be better understood. It is why we are often so successful. It doesn’t take much motivation to get our people to engage a fire. It is who they are. It is why they signed on. It is also why we have mass casualty events.

Who wants to be the first one to pull out? Who wants to be the first one to question the boss or tell the homeowner it was unsafe to protect their home? Who was going to say no to Hancock on the afternoon of July 2? Who is going to say it is too steep or too dry or too dangerous? Who is going to define acceptable risk?

That’s why we need to be real about accepting risk. Hancock assigned the mission. We assign the missions. We are the system that accepts the loss.

So yes, it is about risk and it is about leadership. More importantly, it is also about how we have normalized risk by simply allowing our people to be who they are. How we continue to fool ourselves with misdirected blame, mitigated language, and layers of process.

It is wrong to continue to expect our firefighters to manage risk at the tip of the bayonet. Even with all of their skill and training, sooner or later they will not be able to manage the risk we transfer to them. We must first admit that we accept loss before we can begin to reduce it.

Complexity and System Failure

Thirty-Mile, South Canyon, Dude, Esperanza, Yarnell Hill and countless other fires were not simply human error or unexpected weather events.

These fires were the result of a culture that allows humans to excel. Excel to the point of a systematic failure—to try to hold the line when conditions are extreme; to accept great amounts of uncertainty.

All of these fires have two reoccurring themes: Complexity and System Failure. Fuels, Weather, Topography and People—all four of these elements were in place and just happened to be complex enough at one level or another to outpace the group’s ability to adapt to changing conditions.

The best equipment and technology in the world cannot save a mountain climber in an avalanche or bring a spacecraft home safely. There is too much uncertainty built into these complex systems. Getting it right most of the time is quite impressive. Getting it right all of the time may not be possible. Complex systems have complex problems.

Like the rest of the world, the complexity of the fire environment has changed.

All the data supports a “new normal” in our business: an environment more complex than the system that we designed to manage it. It is a system designed around human decision-making. So, how are we changing? How do we create a greater degree of margin in the system so we can maneuver in the face of uncertainty?

How do we develop a more resilient system to respond to changing conditions and to learn from failure? How do we think and lead like Hancock without relying on the sacrifice of the Private to be successful?

What is Our Acceptable Level of Risk?

Is acceptable risk captured in WFDSS? Is it communicated on the ICS 215 and 215a? Do we share it at the morning briefing? (“Briefing”—yet another verb [to brief] that has become a noun in our language.) If we are unable to define acceptable risk then we must be willing to accept it with whatever loss occurs.

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Acceptable Loss or Normalizing Risk? 
Please Help Define What We Need to Address

After writing down my thoughts from my experiences at 1st Minnesota and getting feedback on this topic, it is clear that I am talking about two separate—but closely related—issues: Normalizing Risk and Acceptable Losses.

They are so closely related that I have struggled separating them in this article. Perhaps I am oversimplifying a complex issue. Discussing one takes me right to the other. I could therefore use your assistance.

Please help define what we need to address.

Use this link to submit answers to the following questions:

  • How do we view loss in the wildfire community?
  • What parts of our culture place us in the greatest danger?
  • Under what circumstance could a bad thing happen to you?
  • How does recognizing our limitations ultimately improve our performance?


It’s your responsibility to have an opinion on these topics. Discuss these issues with those around you.

Help develop a culture that supports open dialogue and grows as a result.

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Curtis Heaton is the Operations Section Chief for the Phoenix NIMO Team and a Lead Instructor for L-580 Gettysburg Staff Ride. 

Thanks to the Wildland Lessons Learned Center for this post. Printed in the Spring 2015 issue of Two More Chains.

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