“Doctrine Dialogue”

Using Risk Management to Promote a Learning and
Safety Culture

Update: Spring 2010

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“Organizational learning is crucial to risk management. It is essential we review our successes as well as our failures to promote and strengthen our safety culture.” – (Regional Forester)

Improving the safety culture of wildland firefighters remains at the forefront of the Forest Service Fire and Aviation Management Program. Fundamental Doctrine Principles continue to evolve by incorporating sound risk management practices into contemporary learning techniques that focus on holistic systems management and aggressive risk assessment. Improving fire line communications and fire line decision-making, along with instilling high reliability organizing into fire organizations, all serve to promote the Learning & Safety Culture. Recent hallmarks of the Risk Management program include new systems management practices and incident reporting tools that allow fire fighters to feel confidence and trust in practices that incorporate transparency and strive to eliminate blaming.

“The aviation environment is a complex, high-risk environment. The aviation organization will aggressively apply the principles of risk assessment and risk management.” – (Aviation Manager)

In the aviation environment, Safety Management Systems or SMS is a proven practice being utilized to bring formal structure to managing the risks associated with multiple aspects of fire aviation. The goal of SMS is to create a positive safety culture where practitioners continually challenge existing aviation practices, culture and systems in order to identify weaknesses and to identify where improvements can be made. The SMS program is based on the pillars of Policy, Risk Management, Quality Assurance, and Safety Promotion. A vital part of SMS is the ability to accomplish key risk assessments. Learn more about SMS by visiting the Aviation Safety website at http://www.fs.fed.us/fire/av_safety/ . For more information on risk assessments visit: http://www.fs.fed.us/fire/av_safety/risk_management/index.html#tb

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For the fire ground, the Accident Prevention Analysis or APA was developed to help extract lessons learned in order to prevent repeat types of accidents. At a recent workshop in Sacramento a diverse group of participants took part in the first ever APA workshop. Based on contemporary doctrinal principles, such as Just Culture and storytelling, the APA is used with the intent to openly gather lessons learned from actual participants involved in accidents and near-misses. Created in a manner that calls for multi-level trust and open communication, an APA is conducted with the primary intent of learning what caused unintended outcomes. The APA is gaining traction as an effective tool for teaching “why” accidents occur and the conditions that led up to them, rather than who caused them. The APA tends to eliminate the common human factors trait of hindsight bias, often referred to as “arm-chair quarterbacking” or “looking back at human error” on why bad outcomes occurred, which is all too often associated with traditional accident reviews and investigations. Information on the APA process can be found at http://www.fs.fed.us/fire/doctrine/index.html.

Because all accidents are preventable, risks can and should be mitigated to the extent possible. There is much to learn in these evolving areas. Tools like risk assessments and APA’s – help the safety culture continue to evolve. For more on lessons learned from APA’s and other reviews visit: http://iirdb.wildfirelessons.net/main/Reviews.aspx

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