HROs: Mindful Management of the Expected

High reliability organizations (HROs) understand that small problems can become big problems and respond to weak but significant signals with a strong response. To state it another way: Good management of the unexpected is mindful management of the expected.1 It turns out the unexpected often takes place in the earliest stage of a problem and gives off weak signals that are often missed or normalized as a cost of doing business. Organizations sometimes fail to keep a small problem small by employing a weak response to a weak signal. The hallmarks of HROs are the following: preoccupation with failure, reluctance to simplify interpretations, sensitivity to operations, commitment to resilience, and deference to expertise. (1)

This article discusses several parallels between HROs and my former fire department. How does your department compare?


Tailboard Talk: Introduction to Higher Reliability Organizations

Tailboard Talk: HROs Use Human Factors to Improve Learning Within the Organization

Mistakes Even Happen to Firefighters: A Preoccupation with Failure

Tailboard Talk: Is the Fire Service Highly Reliable?

Preoccupation with Failure

HROs highlight near misses and guard against complacency; they understand that success means the unexpected hasn’t happened yet. They accept that surprise and errors are hard to anticipate and are often unavoidable; they spend as much time concentrating on lessening the impact of an event (mitigation) as they do preventing the avoidable from taking place.

The Fire Department of New York Center for Terrorism and Disaster Preparedness develops “all-hazard” emergency response exercises. The exercise group often conducts a run-through of an exercise several days before the event to identify and resolve any obstacles—for example, if the location can adequately support the exercise and if the theatrical smoke machines will trip the circuit breakers. After it was determined that the site could accommodate the exercise and after a work-around session to sidestep any problems that could not be eliminated was held, the exercise took place without a hitch. Had the Center not “pre-gamed,” a major exercise objective (search and rescue) may have been compromised. Author Annie Duke calls this run-through a “premortem”—“working backward from a negative future.”2

Does your department anticipate failure? Do you play the “what if” game when critiquing fires? Forget about Plan B. Do you have a Plan C when Plan B doesn’t work? Do you look for the unexpected when you don’t recognize what’s expected? Learning takes place in the brief moment between being surprised and normalizing. (1)

Reluctance to Simplify

“HROs simplify less and see more.” (1) They spend less time trying to explain anomalies away and strive to recognize “weak signals” in the incident quickly. Understanding the complexities of an incident makes it easier to focus on the smaller details. Complexity involves seeing the “big picture,” employing the different levels of situational awareness (SA) to help them make sense of their world. SA is defined as the perception of the elements in the environment within a volume of time and space, the comprehension of their meaning and the projection of their status in the near future. In other words, we perceive a problem (Level 1), comprehend the problem (Level 2), make a decision based on good information (Level 3), and make sure the decision produces the expected outcome (Level 4).3


Imagine a seasoned chief officer and a newly promoted probationary firefighter standing in front of a burning building, sizing up the situation. The building is a four-story, wood-frame structure in a row of similar attached buildings. The fire is on the top floor. Both individuals perceive the same set of circumstances (top-floor fire). However, the seasoned officer understands fire behavior and building construction and that the fire will now begin to spread horizontally; the less experienced firefighter may not see this. Using existing cues, both individuals have entered Level 2 SA. One of them, however, is at a distinct disadvantage. The chief, who does not want to simplify, will seek input from operating personnel who challenge his interpretation of the scene.

Chiefs have good imaginations because they have a wealth of past experiences—a mental imbedded file cabinet of what has and has not worked in the past.4 Because they are seldom the first unit on the scene, while en route, they scrutinize details of the incident (building address, construction and occupancy type, time of day, fire location, and so on). Using incident details, coupled with similar past incidents, the chief paints a mental picture of what the scene should look like. This masterpiece is the chief’s mental model of how the world works. Mental models allow the chief to use long-term memory stores to understand and solve present-day problems.

On arrival, the chief takes in the “big picture,” visually triaging the scene while maintaining that 30,000-foot view. He compares his masterpiece to what is taking place. Sometimes, they are similar; other times, they are not. The chief makes adjustments based on new information and feedback from those on the scene. Complexity and attention to details help the chief to remain focused and not to marginalize what is taking place. An effective method for overcoming the temptation to simplify is to create diversity within your organization. Diversity creates competing viewpoints that allow people to see different things when viewing the same event—not unlike the chief soliciting feedback because he is unwilling to simplify interpretations of his solitary point of view.

Sensitivity to Operations

A fire protection sprinkler is a building’s greatest ally. It is designed to extinguish or keep a small fire small and isolated. HROs recognize anomalies while they are still small and can be isolated. They do this by paying attention to the small details and encouraging people to share what they know, no matter how trivial it may seem. It’s a mistake to assume everyone knows what you know.

Encouraging and rewarding individuals for sharing information is good business! However, there are a few pitfalls. For example, organizations that create a bias toward the message because they don’t like the messenger will soon find out that the messages (intelligence) come to an abrupt stop. One way to work around this is to “disentangle the message from the messenger.” (2) In other words, imagine the message is from a source you value. Knowledge is power; and contrary to popular belief, it’s most powerful when shared. Many trivial episodes often create patterns that signal a significant problem if ignored—not unlike the sprinkler system!

Decision makers dealing with uncertainty will begin to identify irregularities (by recognizing cues) based on their expectations in previous experiences or known patterns of behavior. (3) Is your department cutting off potential problems at the pass? Or, are you normalizing inconsistencies until they become accepted norms, writing them off as a cost of doing business? Normalizing is the precursor to complacency and creates blind spots in the big picture. One way to maintain sensitivity to operations is to reduce an individual’s span of control, the maximum number of subordinates a supervisor supervises.5

This number can be as low as three and as high as seven. Five is ideal. Most fire departments observe this officer-to-firefighter span-of-control ratio. For example, incident commanders (ICs) often employ the incident command system (ICS) at a multiple-alarm response to help maintain their span of control, thereby ensuring a sensitivity to operations. When ICs’ span of control is unmanageable, they delegate responsibility by establishing all or parts of a general staff (Operations, Planning, Logistics, and Finance6). The span of control is now reduced to a manageable number because the IC is now managing “chunked” sections and the chiefs are managing the sections under their command. The division of labor allows information to flow across and up the chain of command to improve everyone’s SA and enables the IC to remain sensitive to operations, reducing the odds of missing clues that are signaling the unexpected.

Commitment to Resilience

HROs “plan for the worst and hope for the best.” (1) They understand that no environment is error free and don’t allow errors to thwart them from achieving their objective. They turn failures into learning opportunities that lead to success. We’ve all heard the expression, “If you’re not making mistakes, you’re not trying!” Mistakes become an issue when they are repeated over and over again because learning is not taking place. This is when a Plan B comes in handy.

HROs keep errors small while improvising work-arounds. For example, fireground strategy and tactics don’t always work out as planned. Firefighters learn this quickly the first time they apply book theory to the world of firefighting, which is comprised of the unexpected—hydrants freezing, roofs collapsing, hoselines kinking, and so on. HRO fire departments expect the unexpected: They plan for worst-case scenarios just in case they come to fruition. They identify firefighter assist and search teams (FAST) whose sole purpose is to assist firefighters in distress and establish staging areas for reserve apparatus at multiple-alarm assignments should operating units need relief or conditions worsen. A football team can practice all week to defeat the opponents, studying their strengths and weaknesses, only to fumble the opening kickoff. Things seldom go as planned!

The ideal time to hone your commitment to resilience is when critiquing recent fires and near-miss incidents. Remember, just because something bad almost happened but did not happen is not an excuse to forgo turning the near-miss incident into a learning opportunity. You weren’t good; you were lucky! (2) It is important to separate luck from skill. Both outcomes are opportunities to learn.

A postfire critique is best conducted on the back step of the apparatus before leaving the scene because firefighters will recall not only what they did but also how they would do it differently the next time. This is an officer’s opportunity to display leadership by highlighting actions taken: what they could have done better and how they overcame adversity on the fireground. Acquiring knowledge based on the choices we make, whether good or bad or luck or skill, is a key to resilience.

A poker player can win with a weak hand because another player folds. Was this skill or luck? If he chalks it up to skill, he may be in trouble because the same weak hand will usually lose. Are these outcomes just bad luck? Probably not. (2)

Are you chalking up near misses on the fireground to luck, or did skill sustain the near miss? It’s hard to tell. Every decision we make is a bet that often produces immediate outcomes. (2) The learning loop is as follows: We have a belief. We place a bet (decision). We evaluate the outcome. We place a second bet (based on outcome). What needs to be stressed is the influence of luck and skill on the outcome and understanding the difference between the two. (2)

Deference to Expertise

Deference to expertise, although last, is not least. In fact, having younger, novice firefighters leveraging the experience of senior, more experienced firefighters may be a department’s greatest training asset. Who better to learn from than those who have been there, done that—your department’s subject matter experts (SMEs)?

In the 1960s television series Star Trek, the spaceship’s captain, James Kirk, was an effective leader but never the smartest person on the ship’s bridge. He didn’t have to be. He just needed to know who the smartest person was when he needed an SME.

Like Kirk, HROs push down decision making. Authority migrates to the people with the most expertise, regardless of their rank. (1) And, because experience is no guarantee for expertise, HROs often look to decision makers who have experience with a specific type of event.

For example, even though a chief officer assumes the role of IC at a hazardous materials spill, he may seek the guidance of a subordinate officer from the hazardous materials unit because that individual brings an expertise to the incident the chief does not. This is not much different from Kirk’s consulting his science officer (Mr. Spock) about how to ward off the next alien attack or the ship’s engineer (Scotty) on how fast the ship can “warp speed” to the adjoining universe and escape danger. (I’m dating myself here, but you get the point!)

Thesis Research

In my Naval postgraduate thesis “First Responder Problem Solving and Decisions Making in Today’s Asymmetrical Environment,” I addressed the issue of whether the decision-making skills of newly promoted fire officers can be enhanced through training designed to develop those skills. (3) The training consisted of practice with asymmetric terrorist and natural disaster scenarios, expert feedback, and a brief lecture on SA and decision-making strategies.

Three groups were established: control, experimental, and expert. The control and experimental groups consisted of newly promoted fire officers; the experts were 14 FDNY officers who had extensive job knowledge and decision-making experience and were chosen by their rank, years of service, and self-reported domain expertise. An answer key was created: Scenarios were read to the experts and their responses were recorded. The same scenarios were read to the control and experimental groups. One group received expert feedback regarding the decisions made; the other group did not. The group that was given the expert feedback, over time, began to think more like the experts. Their decision making and problem solving were more in line with what the experts did. The other group did not demonstrate these abilities.

This type of learning seems suited to today’s technology; however, this experiment was a simple pencil-and-paper exercise that can be duplicated by crafting effective emergency response scenarios, gathering scenario feedback from your department’s SMEs, and using their feedback when training novice decision makers on the same scenarios. All can be accomplished without leaving the firehouse kitchen. Training void of technology is prone to failure, often holding the learner hostage to a good Internet signal!

The big difference between getting experience and becoming an expert is the ability to identify when the outcome of our decisions has something to teach us and what that lesson might be. (2) Feedback, especially immediately following a decision, is paramount to learning. Successful poker players become excellent intuitive decision makers by placing a bet and receiving immediate feedback. Did they win or lose? The good ones learn from feedback; the bad ones do not. This is not much different from real life.

HROs understand that failure is a real possibility, learn from mistakes and avoid complacency, play the “what if” game and devise contingency plans, think outside the box, see the big picture by not missing the small cues, and leverage expert feedback.

Fire departments can manage the unexpected by acting more like an HRO, replicating their capability for mindfulness. Using mindfulness and good SA, you can perceive the problem, understand its capabilities, and take steps to prevent or mitigate its impact. Is your fire department an HRO?


1. Sutcliffe, Kathleen M., Weick, Karl E. Managing the Unexpected: Assuring High Performance in an Age of Complexity. San Francisco, CA: Jossey-Bass. 2001.

2. Duke, Annie. Thinking in Bets: Making Smarter Decisions When You Don’t Have All the Facts. New York, New York: Portfolio / Penguin. 201.

3. Hintze, Neil R. “First Responder Problem Solving and Decision Making in Today’s Asymmetrical Environment.” Naval post-graduate master thesis. 2008.

4. Klein, Gary A. Sources of Power: How People Make Decisions. Cambridge, Mass: MIT Press. 1998.

5. Essentials of Fire Fighting and Fire Department Operations. Upper Saddle River, New Jersey: Brady. 2013.

6. Deal, Tim, Michael de Bettencourt, Vickie Huyck, Gary Merrick, Chuck Mills. Beyond Initial Response: Using the National Incident Management System’s Incident Command System. Bloomington, IN: AuthorHouse. 2006.


Neil R. Hintze retired as a battalion chief from the Fire Department of New York (FDNY) in 2014 after 35 years of service. Before retiring, he was a field commander in Battalion 47 and supervised the FDNY First Line Officers Training Program Leadership/Management, Decision Making and Problem Solving curriculum for newly promoted New York State fire officers. He is an instructor at Nassau Community College, lecturing in fire operations and emergency management. He develops, designs and conducts “all-hazard” exercises (tabletop/full-scale exercises) for private and public colleges/universities throughout the country. He has a B.A. in American studies from SUNY, a master’s in education from Queens College, and a master’s in security studies from the Naval Postgraduate School. He is a FEMA master exercise practitioner.

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