2020 WOR Day5: Learning to Change

Category: 
Week of Remembrance
Page Last Modified / Reviewed: 
Jun 2020

 

A famous anecdote describes a scheme the British Colonial Government implemented in India in an attempt to control the population of venomous cobras that were plaguing the citizens of Delhi that offered a bounty to be paid for every dead cobra brought to the administration officials. The policy initially appeared successful, intrepid snake catchers claiming their bounties and fewer cobras being seen in the city. Yet, instead of tapering off over time, there was a steady increase in the number of dead cobras being presented for bounty payment each month. Nobody knew why. (“Our World” by United Nations University)

How do we as leaders seek out to change what is not working?  The wildland fire community has implemented the process of Reviews, Facilitated Learning Analysis (FLAs), and Rapid Lesson Sharing (RLS) as a mechanism to learn from unintended outcomes.  This process also allows us to examine our culture and implement continuous improvement.  Continuous improvement is an operational imperative to leverage experience and to ensure each subsequent project can be executed at the highest quality, in less time, at a lower cost, and with fewer mistakes.

Recommendations and Implementing Them

“….you can’t change the human condition; but you can change the conditions under which humans work” – James Reason

Reviews and FLAs may come with recommendations of how to seek change, the intent of change is to reduce a recurrence of the incident.  We cannot eliminate the possibilities of an incident occurring again, but we can actively manage our actions to reduce the chances.  A safety culture is dependent upon a learning culture and in turn, learning is dependent upon leaderships’ willingness to change.  Recommendations provide a framework of lessons learned and options created by subject matter experts, for how to move forward.  Good leaders see recommendations as a value to the organization as opposed to a judgement of their abilities as a leader.  By not seeing the value and importance in recommendations, and seeking improvement within the organization, leadership sets the stage for a repeat of the incident and fails the culture of safety and improvement. 

By now, you may have figured out what happened in the Delhi anecdote with which we opened. Realizing that the cobra bounty converted the snakes into valuable commodities, entrepreneurial citizens started actively breeding them. Under the new policy, cobras provided a rather stable source of income. In addition, it was much easier to kill captive cobras than to hunt them in the city. So, the snake catchers increasingly abandoned their search for wild cobras and concentrated on their breeding programs. In time, the government became puzzled by the discrepancy between the number of cobras seen around the city and the number of dead cobras being redeemed for bounty payments. They discovered the clandestine breeding sites, and so abandoned the bounty policy. The breeders, now stuck with nests of worthless cobras, simply released them into the city, making the problem even worse than before!

It is true recommendations may not yield the positive changes that were anticipated but it is a process that we must embrace, evaluate, and learn from so that we can continue to seek improvement in our culture. 

Watch this TEDx on Leading Change with Humble Audacity


Time: 9:56

A purple ribbon symbolizing remembrance of those who have passed away.Discussion Questions:

  • What lessons has your crew learned and what changes have you made as a result of those experiences?
  • What lessons have you taken away from an FLA that you didn’t agree with and why?
  • What was the alternative recommendation you implemented and did it result in positive change?

 

Additional Resources

Incident Management Situation Report (IMSR)
Incident Response Pocket Guide (IRPG), PMS 461
NWCG Standards for Helicopter Operations, PMS 510
RT-130, Wildland Fire Safety Training Annual Refresher (WFSTAR)
Interagency Standards for Fire and Fire Aviation Operations (Red Book)
Wildland Fire Lessons Learned Center

Have an idea? Have feedback? Share it.

EMAIL | Facebook | URL: https://www.nwcg.gov/committees/6-Minutes-for-safety
MAIL: 6 Minutes for Safety Subcommittee • 3833 S. Development Ave • Boise, ID 83705 | FAX: 208-387-5378