Tailboard Talk: Introduction to Higher Reliability Organizations

By Dane Carley and Craig Nelson
Six years ago, 200 fire service leaders attended a summit to seek answers to the fire service’s ongoing annual loss of about 100 firefighters. Two things came from the summit: The goal to reduce line-of-duty-deaths (LODDs) by 50 percent in 10 years, and the 16 Life Safety Initiatives that would guide the fire service toward that goal. Six years later, the fire service still sees about 100 firefighter LODDs a year. Why does the fire service continue to lose the same number of firefighters? It seems like every time we turn around, someone is preaching safety, yet the LODD numbers stay the same. Why is that, and how many times have we heard this? We have good, inspiring leaders who recognize the problem and provide solutions. We have good firefighters and company officers who know their jobs inside and out. They follow the rules, use solid safety practices, and train more often than ever before. Leaders, firefighters, and company officers alike are well trained, well educated, and experienced. Therefore, we believe the problem lies within the number of rules, current safety practices, and our approach to safety.
Advocated by Everyone Goes Home, the 16 Life Safety Initiatives are a good departure from many of our safety programs, because they begin to explore a short list of root causes. Many of our safety lists are too long and complex to remember, containing only symptomatic instructions like “Wear your seat belt” and “Put on your SCBA” instead of addressing the root problem or behavior. The problem is that 80 percent of the reported near misses come from human behavior that leads to accidents or incidents, and not the symptoms of that behavior (Carley, 2010). Therefore, we need a comprehensive plan that addresses the fundamental behaviors causing many of the LODDs and injuries. This means a change in the way the fire service approaches its business.
Other industries operating in a similar environment where there are severe consequences for a single mistake do not see similar accident statistics. What do they do differently? For one, these industries have aggressively implemented comprehensive programs based on principles that have produced up to an 80-percent reduction in fatal accidents and injuries. Imagine up to 80 fewer line of duty deaths and 80,000 fewer firefighter injuries. Is it possible? We believe it is. 

It is possible if we shift our focus away from treating the symptoms causing our LODDs and injuries, and begin looking at the root causes, which usually leads to human factors. In this column, we will begin building a comprehensive system that addresses operations, prevention, and quality control using components the fire service already has in place. This system, already used in other industries, is called a High Reliability Organization (HRO).

Some people and researchers already refer to the fire service as an HRO, but it is important to note the definition of a HRO. “An HRO is an organization operating in a complex, high-risk environment in which a single error has the potential for disastrous consequences, yet the organization routinely performs with a low number of errors due to various organizational characteristics intentionally engineered to prevent human error ‘that will continually delay or even permanently defer the inevitable failures.’ (as cited in Erickson & Dyer, 2004, p. 8)” (Carley, 2010). An HRO accomplishes this by consciously implementing a comprehensive plan that hinges on developing a learning culture within an organization using methods such as near-miss reporting and root-cause analysis.

An HRO recognizes that organizations are comprised of humans who, no matter how diligent they are, make mistakes. In organizations like the fire service, we must first accept that we all make mistakes, no matter how smart, educated, or talented we are. An HRO builds systems on five basic principles to prevent a mistake, compensate when a mistake does occur, and then learn from the mistake to prevent it from occurring again. Weick and Sutcliffe (2007) list the principles of an HRO as: 
  • Preoccupation with failure
  • Reluctance to simplify
  • Sensitivity to operations
  • Commitment to resilience
  • Deference to expertise

These principles are evident in fire service systems such as FIRESCOPE ICS and quality assurance (QA) programs associated with advanced life-support programs. However, these systems are in silos instead of being integrated components of a larger HRO system. An HRO incorporates multiple systems like the previous two, plus Crew Resource Management (CRM), understanding human behavior, and leadership into a comprehensive system. Therefore, all of these become interrelated components in the context of the five HRO principles. Every aspect of the organization is trended on data collected from near-miss reporting, QA programs, and root-cause analysis. They are measured against the principles of ICS and CRM and judged on how the behavior aligns with HRO principles. 

We hope to explain the HRO concept to the fire service in this column and begin to develop an understanding so the fire service can realign current systems into a comprehensive higher reliability organization. HRO concepts and systems cover a broad range of topics, including:

  • Human factors
  • Situational awareness
  • Crew Resource Management
  • Near-miss reporting
  • Tracking and trending near misses
  • Organizational behavior and culture
  • Leadership development
  • Group development
  • The acceptance of organizational change

We hope the fire service will witness a paradigm shift that focuses decision making and safety practices onto a few fundamental firefighter behaviors instead of attempting to fix thousands of symptoms contributing to firefighter accidents. We plan to do this by reviewing case studies of incidents taken from the Firefighter Near-Miss Reporting System, then creating questions or exercises to aid in learning the material for each article. In the next column, we begin exploring human factors and the relationship human factors have to the HRO concept.

We would appreciate any feedback, comments, or suggestions. Please contact Craig and Dane at tailboardtalk@yahoo.com.


Carley, D. A. (2010). Working Paper on the Development of a Fire Department Into a High Reliability Organization. St. Cloud State University. Fargo, ND: Fargo Fire Department.

Erickson, D., & Dyer, L. (2004, March). Toward a Strategic Human Resource Management Model of High Reliabilitiy Organization Performance. Retrieved February 18, 2010, from Cornell University ILR School: http://digitalcommons.ilr.cornell.edu/cgi/viewcontent.cgi?article=1008&context=cahrswp

Weick, K. E., & Sutcliffe, K. M. (2007). Managing the Unexpected 2nd Ed. San Francisco, CA: Jossey-Bass.

Craig Nelson (left) works for the Fargo (ND) Fire Department and works part-time at Minnesota State Community and Technical College – Moorhead as a fire instructor. He also works seasonally for the Minnesota Department of Natural Resources as a wildland firefighter in Northwest Minnesota. Previously, he was an airline pilot. He has a bachelor’s degree in business administration and a master’s degree in executive fire service leadership.

Dane Carley (right) entered the fire service in 1989 in southern California and is currently a captain for the Fargo (ND) Fire Department. Since then, he has worked in structural, wildland-urban interface, and wildland firefighting in capacities ranging from fire explorer to career captain. He has both a bachelor’s degree in fire and safety engineering technology, and a master’s degree in public safety executive leadership. Dane also serves as both an operations section chief and a planning section chief for North Dakota’s Type III Incident Management Assistance Team, which provides support to local jurisdictions overwhelmed by the magnitude of an incident.

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