Appendix D: Findings From the Wildland Firefighters Human Factors Workshop, 9551-2855-MTDC

Findings From the Wildland Firefighters Human Factors Workshop

Appendix D—Keynote Presentations

Cultural Attitudes and Change in High-Stress, High-Speed Teams

David O. Hart, TID, Inc.

What is Decision Making?

As we saw in the other presentations, there are a variety of ways to model decision making. The importance here is that it can be modeled, described, and examined. By examining decision making as a system, we can learn how attitudes, individual and cultural, affect the quality of our decisions.

There are as many decision making definitions as there are models. For this discussion we'll need to have a common reference to work from when talking about decision making. Also, because we are talking about organization and team decision making, we'll focus the following definitions in that direction. A definition of decision making to keep in mind during this discussion is:

The process "of reaching a decision undertaken by interdependent individuals to achieve a common goal. What distinguishes team decision making is the existence of more than one information source and task perspective that must be combined to reach a decision."

Decision Making Factors

Close examination of this definition reveals many important aspects of the decision making process in high-stress environments. These include, but are not limited to:

Ill-structured problems
Uncertain, dynamic environments
Shifting, ill-defined, or competing goals
Action-feedback loops
Time stress
High stakes
Multiple players
Organizational goals and norms

All these factors affect how well the decision making machine works. If you think back, you've probably encountered most (if not all) of these factors during fire fighting operations.

DM and Attitudes

In this discussion, the factors we'll be concerned with are those that relate to and affect cultural attitudes. In general, attitudes that enhance the DM process are seen as positive, and those that act as barriers to effective DM as negative. Many attitudes have both positive and negative effects. All this may seem intuitively obvious to even the most casual observer, but it is important to establish a common ground before we delve too deeply into this subject. In the spirit of "crawl, walk, run" we'll need to first understand how attitudes affect the individual before we can understand the impacts of cultural attitudes on an organization.

Attitudes and the Individual

Before we go too much further, we'll need another definition. This time we'll be defining attitudes.

The American Heritage Dictionary of the English Language defines attitudes as: "a state of mind or a feeling; disposition." A longer definition is: "An enduring organizational, motivational, emotional cognitive process with respect to some aspect of the individual's world. Attitudes and beliefs imbued with emotional and motivational properties." Another shorter definition, is: "Affect for or against a psychological object."

They all say the same thing—an attitude is how you feel about something. Now that we know what attitudes are, let's see where they come from.

Generally, your experience forms, has an effect on, or shapes your attitudes. Some attitudes may last only minutes, others a lifetime. Another way of looking at it is to say that your attitudes come from your values and goals (remember those DM factors). So the attitudes you use as firefighters come from your training and experience as firefighters.

What Do We Do with Attitudes

Attitudes help us make sense out of our surroundings and allow us to build and maintain our Situation Awareness (SA). How? By providing each of us a set of rules and guidelines we use to gather and process information. Therefore, attitudes aid in our decision making by framing and shaping the information we use to make our decisions. You could almost say that attitudes are imbedded in every aspect of decision making. Good, bad, or indifferent, attitudes affect the quality of our decisions.

On a team, the synergy that develops can compensate for attitudinal failures or barriers in one of its members. Effective teams recognize attitude problems and find ways to work around the "attitudinal outages". A good example of this is the issue of women as crewmembers in combat aircraft. Many male aircrew have a real " attitude" about women in the cockpit. Probable fallout from this barrier is reduced communication, increased stress, conflict, with a resulting loss of efficiency and effectiveness. A good team will recognize the barrier and react by:

Increasing communication to and around the affected people
Closely evaluating the information sent by the affected parties to weed out any attitude biases
Finding ways to reduce stress (knowing military crewmembers, humor would be a likely choice)
Defusing any conflict before it engages the entire crew.

We've looked at the what, how, and why questions regarding attitudes and the individual, and even looked briefly at a possible individual attitude outage scenario and the team's possible response. Now let's turn our focus to teams.

Attitudes and the Team

Cultural attitudes—what are they, and why are they different? As to what they are, our definition is still valid, but with this added: the attitude is shared by every member of the organization. Organizations and teams use attitudes for the same purpose as individuals, to build and maintain their knowledge of the environment. The big difference is that the synergistic effect of teams magnifies and multiplies the effect of attitudes.

The multiplication and magnification cuts both ways. Positive attitudes provide a uniform strength and negative attitudes, uniform weaknesses. An example of a positive effect is providing baseline goals, values, and priorities (once again, remember the DM factors), to establish a cohesive team more easily and quickly. Failures are much more insidious.

When an attitude fails (e.g., is no longer valid) or is working against a team, it becomes an attitudinal "blind spot." Because everyone in the team and/or organization possesses the attitude, no one can perceive that there is a problem—there is nothing to compare it against. For example, the team has an attitude barrier that inhibits communication. By reducing the amount of information flow, and possibly, information quality, there can be a substantial loss of synergy, cohesiveness, leadership, recognition, awareness, and communication. All these elements, working at full capacity, are crucial to effective decision making.

It is important to note that despite these undesirable results, critiquing and correcting the failure is difficult because you can't "see" the cause.

Where Attitudes Come From

We've already determined that an individual's attitudes come from his or her values and goals. The same holds true for any organization. The cultural attitudes grow out of the organization's values and goals. The source for these attitudes can be either internal or external to the organization.

Internal sources are the easiest to identify. Policy statements, directives, and even official memos are examples of how organizational goals and values manifest themselves.

Looking to the South Canyon Fire (SCF) incident, the Grand Junction District Management Team directive that all fires be "initial attacked and suppressed as soon as possible" is an example of policy working as a cultural attitude. What you gain from this attitude is a concrete direction for the firefighting teams. The goals of their decisions are unambiguous. On the flip-side, this attitude can become a decisional oneway road. It doesn't provide a way out of a fire that cannot be suppressed. Also the added emphasis on mission accomplishment can come into direct conflict with existing safety attitudes.

The "can do" attitude identified in the SCF investigation report is common to many high stress, high speed teams. It helps build team cohesion, which is important to the team for synthesizing information and integrating the individual perceptions of the situation into a common perception. But taken too far, this attitude can have lethal consequences. By going above and beyond to complete the job, mission success is prioritized ahead of safety. We see this in the report where the " can-do" attitude is attributed with the compromise of the 10 Standard Firefighting Orders (SFOs) and 18 Watch Out Situations (WOSs).

When there is a disconnect between training and experience, a barrier to effective decision making exists. This disconnect causes a gap between the individual and resulting team perception of reality and actual reality. This example is more ambiguous than the previous two, but when seen in an actual example, it leaps right out at you. The SCF report found that "some firefighters failed to recognize the capability and limitations of the fire shelters and deployment sites." And "some questioned the value of the fire shelters under any conditions and may not have been carrying shelters." It is apparent that the training received was not supported or validated by the experience of the cited firefighters. This kind of gap between perception and reality can, and has produced, deadly results.

The final internal example is the attitude or sense of being part of a larger " family." This is most often seen as an elitist attitude. In this case we use elitist to mean special, different, or set apart. It is often expressed with the statements " we watch out for our own," or "we take care of our own." This increased awareness of your teammembers translates into an increased safety awareness. Carried to an extreme, it can result in a lack of leadership. The B-52 bomber crash at Fairchild AFB in Spokane was allowed to happen because the commanders at the base failed to ground the pilot for flying the aircraft outside its operational limits because, he was "one of our own," and for fear of "ruining his career."

For external sources of organizational attitudes, we'll look at two particular to firefighting, and one common to the entire federal government.

Pressure from the public and media generates the attitude that fires with the most public attention should be attacked first. Normally, being responsive to the needs of your customer is seen as a positive goal and attitude. But by allowing people outside the organization to control priorities, you end up with shifting, ill-defined, or competing goals (sound familiar?).

The harsh spotlight of the news media can have a similar effect. An organization is usually highlighted because of some failure or near-failure. The organization usually responds by reacting with abrupt changes in goals and values, then attitudes, then decisions. In the case of the SCF, the reaction was increased emphasis on safety, but unless the spotlight is on something that needs to be changed, the resulting changes may not be for the good of the organization.

The last external example is one that everyone connected with the federal government, most state governments, and some corporations have felt: "do more with less". In a perfect world this would allow organizations to get the most from their resources. Unfortunately, we don't live in a perfect world. In reality, this attitude is a time bomb just waiting to go off.

" Do more with less" pushes people and equipment to perform beyond their capabilities, usually by sacrificing the normally accepted margins of safety. It usually takes a catastrophe many times worse than the SCF for the federal leadership, from Congress on down through each agency involved in the concerned operation, (in this case wildfire fighting) to realize that you do less with less. Adopting a "do less with less" attitude would mean letting some fires burn themselves out when they don't directly threaten the local populace. Unfortunately decisions like these usually come at an immeasurable cost.

Attitudes, Training, and Experience

Attitudes, training, and experience have a deeply interrelated relationship. Cultural attitudes affect the emphasis of training, and experience shapes and modifies our attitudes. When experience and training validate each other, there is usually a positive attitude effect. When they don't support each other, there's usually a negative attitude effect.

Start with the training attitude that by emphasizing fire behavior, fuels, weather, and tactics, entrapments will be avoided. Add to that the historically low frequency of losses, an experience based invulnerability attitude (i.e. "it won't happen to me") can develop. The overall experience, expertise, and success of firefighters fosters the attitude that they can handle any fire (i.e. elitist, can do, or 10:00 fire), which in turn feeds the training and experience attitude "why should we over-learn emergency procedures (fire shelter use and bailing out of a situation). From this vantage point, it would appear that these attitudes are leading firefighters to lean on luck and circumstance to keep them safe.

The combination of low frequency of losses (experience), and highly experienced teams (experience) conspire to subvert important safety procedures and attitudes (training).

Attitude Impacts on SCF

Cultural attitudes played a significant roll at South Canyon. Some of the cultural attitudes that were carried into the fire were:

"All fires will be initial attacked and suppressed as soon as possible."
"Highest priority fires are ones that threaten life, residences, structures, and utilities."
"We can handle the fire."
"Can do"
"It won't happen to me."

This last attitude is a training/experience trap stemming from the fire training attitude and the fire shelter attitude.

What impact did these attitudes have on the incident? First, we need to recognize that safety and operational effectiveness are opposite sides of the same coin. The first Standard Fire Order supports this. At South Canyon, the additional emphasis suppression received was both caused by and resulted in the erosion of safety margins. Each time the firefighters "got away with" pushing into their safety margins to suppress a fire, it reinforced the attitude that they could do the job with a smaller margin for error. The fact that some of the firefighters were uncomfortable with the situation at South Canyon demonstrates that Grand Junction's suppression directive was causing some shifting and competing goals. This erosion of the safety attitude coupled with SA and communication breakdowns critically compromised the team and individual decision making ability. Among the elements that led to this breakdown are physical and mental fatigue, recognition gaps, weather information not communicated or used, safety concerns not communicated, concerns about who was in charge (leadership) and the numerous compromises of the SFOs and WOSs. When the blow-up occurred, these came together with deadly results. The attitudes also blocked the last escape path—dropping tools and packs, bugging out, and using shelters.

After situations like these many questions are raised. Some that need to be answered in order to affect any kind of change are:

Do tactical teams know to increase meaningful communication during a crisis? Also, do they know how to communicate effectively?
What about pre-planning for crisis situations?
Do tactical teams get the best information before and during a fire crisis?

Changing Cultural Attitudes

Before we look at examples of how these changes are affected, let's look at why that change is made.

Why do cultural attitudes change? Because it is recognized that the long term goals of the organization are not being met.

How do you recognize that an attitude is no longer valid? Since you have no " attitude out" light, you usually know by unwanted results produced by practicing the behavior associated with the attitude. The feedback from the environment may be obvious or subtle. Because of the blind spot effect talked about earlier, it is harder for teams to find the offending attitude than for individuals. Organizations, being larger and more complex than their component teams, find it more difficult digging out an invalid attitude.

Why is it harder for an organization to change an attitude? You have many more people needing to change and change is naturally difficult for people. Because they're doing something new and different, it take times and effort to make it stick. Let's look at a typical process by which organizations can change attitudes. Then we'll look to commercial and military aviation as examples of organizations that have undertaken this kind of change.

Preliminary Requirements. Before the change process can be started, the organization, in particular the senior leadership and managers, needs to recognize that their greatest contribution to this sort of change is providing a supportive environment that will foster the growth of the change effort.

Patience, perseverance, and commitment from the leadership and managers is absolutely necessary. Recognizing that this sort of change happens one person at a time and that it will be slow and sometimes difficult, they will be supporting the change and their own role in the effort.

For the individual, making the change can be as simple as changing the behavior associated with the attitude. This can happen very quickly, but may not have a lasting effect. As soon as the need for the change has passed, the individual is likely to revert to old behavior patterns and start the cycle all over again. Actually changing the attitude is more difficult than changing the behavior. It takes more time, but has a more permanent effect. For an organization, the time and effort is greatly magnified.

Commitment, or lack thereof, will either make or break this type of program.

What needs to be changed? Initially a survey of the organization should be conducted to determine the attitudes and values regarding team effectiveness. Areas that are typically covered in this type of survey are leadership, communication, recognition and management of stress, needs for achievement, and job satisfaction. For accurate data to be gathered the need for anonymity is essential. In addition a cross-section of the entire organization, top to bottom, left to right, needs to be sampled to prevent inaccurate, misleading, and skewed data. This information is then used as a benchmark to measure the change against, and to help determine the types of tools to necessary to make the change.

How does it happen? Using the data from the survey, a program of change is developed. Usually this takes the form of training or organizational interventions. The program is usually developed by or in conjunction with professionals involved in this arena. Credibility of the developers, program, and delivery personnel is critical to the program's success. This is the first step in assuring the buy-in of the front-line teams.

Finally, programs should be designed to fit seamlessly into the culture. It can't be seen as one time fix or just another training requirement. To change the culture, it must be part of the culture.

Where does it start? Programs which work to improve team attitudes and effectiveness usually consist of a number of inter-connected training modules.

Initial "awareness" training is designed to introduce the program and set the stage for the training to follow. It is usually directed at all organizational members who are targeted for change.

A leadership/management "staff" course for the senior management is also conducted in the initial phases. These programs provide management personnel the essentials to fulfill their role in the change process. They need to "walk the talk" if they expect the rest of the organization to do the same.

Baseline training is the longest and most in-depth phase. It provides the background, vocabulary, skills, and feedback the teams need to affect this change.

Instructors and Evaluators play a special role and therefore need special training. This type of training is focused on observing, instructing, and evaluating the new attitude.

Finally, continuation training provides ongoing reinforcement of the concepts learned in the baseline training. For the best results, it should be practiced in an environment as close to actual as possible.

As with support, training must also run from the top down. No one is exempt from training, no matter what their standing in the organization. Each phase builds on the previous. This continuity is necessary so that previous training isn't invalidated by the next phase. The training that is the most important is usually the most neglected.

Instructor/evaluator and continuation training are probably the two most critical modules for assuring long-term success. The instructors and evaluators must embrace the change and its concepts and procedures, or the training will be useless. Lack of buy-in from the instructors and evaluators can result in training invalidating training, and evaluation invalidating or ignoring training.

Continuation training, on the other hand, keeps the ball rolling. Remember this is a long term program, not a quick fix Band-Aid. These concepts and skills need to be revisited not just annually, but at every training opportunity if it is going to be a permanent part of the culture. As with anything new, practice, practice, practice makes perfect. One final, important point regarding continuation training— Keep it Fresh!! Nothing will kill a program faster than tired, overused training material. As new information becomes available it should be integrated into the program.

Looking back...we see that this is just a sample of what a program for cultural change could look like. A real program is much more complex, but then again, real change is much more challenging.

Other organizations have undertaken to change attitudes within their culture. Most notable is the aviation community. We'll look now at commercial and military aviation to see what brought them there and what they've done and gained.

In the Beginning...

The 1970s saw a number of air carrier crashes. The fact that aircraft crash wasn't new, but the reasons for crashing were. More and more accidents were being attributed to " human" or "pilot error." Highly experienced, trained, and motivated (sound familiar?) crews were allowing aircraft to crash. Most notable is the Portland DC-8 crash where the crew flew the aircraft out of gas while troubleshooting a gear problem on a clear night within sight of their destination. Another is the L-1011 that slowly descended into Florida everglades as the crew tried to decide what was wrong with a 68¢ lightbulb. The crew was focused on the lightbulb and no one was minding the store: why?

The "why?" questions were asked by the airlines also. Human error was the answer—but how do you keep it from happening? This answer took the form of Cockpit Resource Management (CRM).

A program for change was initiated at a number of airlines. It probably looked like the program we just outlined. What they found was that certain elements in the human equation needed change. They were, and are, communication, stress management, leadership, decision making, and attitudes. These programs are designed to make the pilots and flight engineers more effective and efficient flight crews.

As the programs became more and more a part of the airline culture, the benefits of this type of training was seen in other areas within the community. They also started seeing some return on their investment.

A notable (but not isolated) case is the Sioux City DC-10 crash. Enroute to their destination, the #2 engine, the one in the vertical stabilizer, disintegrated. Pieces of the engine cut through the hydraulic lines for the primary, secondary, and standby systems. Without hydraulic power, the pilots were unable to control any of the flight control surfaces. By all rights, the aircraft should have crashed, killing everyone aboard. That's what the engineers at the airline and aircraft manufacturer said. But Capt. Al Haynes attributes his and the passengers' survival directly to CRM. The open, continuous communication, creative synergy, and their recognizing and using all available resources are principles at the heart of CRM, and were the ones used successfully by the flight crew.

Increased focus on and awareness of effective and efficient flight operations helped to broaden the scope of the program. The first to be brought into the fold were the cabin crew, hence the name change to Crew Resource Management. Then it spread to the maintenance organizations.

In the early to mid-1980's military aviation became aware of the benefits of CRM. The USAF Military Airlift Command (MAC) was the first to come on board. Their operations were the closest to the airlines, so it was natural for them to see the benefits first. MAC " spun" the airline programs to better fit their environment. The military was interested in the effectiveness and efficiency issues, but were more interested in CRM's major by-product: SAFETY. In an environment where your enemy is actively trying to reduce you to an aluminum rain shower, a program that keeps you from doing your enemies' job is always attractive!

Today, CRM is an inseparable part of the airline culture. Human factors related accident rates are down, incidents are down, safety is up and so is efficiency. The program is working.

As for the military, the change is still taking root. Military CRM hasn't reached the stage the airlines have, but then as we have said, these things take time. It has also moved out of the aircraft arena. Other military units are seeing the benefits of CRM. Maintenance, test engineers and pilots, and special forces units are just a few that have embraced the concepts of CRM.

Last Words

Changing a cultural attitude can be a daunting process. But in this environment, as in some of the others we've talked about, ignoring an attitude that is in conflict with the organization's goals and values is not just inconvenient, it's downright lethal.

By believing that what you're doing is important, you will be able to make the changes in your culture. These changes will have far reaching benefits for the individual and the organization in safety, decision making, and operational effectiveness.

— TIG, Inc. is a consulting company in Aurora, Colorado. We specialize in the delivery and development of Crew Resource Management (CRM) and human factors training. TIG, Inc. is currently providing services to the Army Guard Special Forces and The USAF Reserves flying and maintenance organizations.