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THE COLLAPSE OF SENSEMAKING IN ORGANIZATIONS: THE MANN GULCH DISASTER - Weick K.E. (1993)
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THE COLLAPSE OF SENSEMAKING IN ORGANIZATIONS: THE MANN GULCH DISASTER - Weick K.E. (1993) Lo scopo di questo articolo è rianalizzare il disastro dell'incendio di Mann Gulch nel Montana descritto nel premiato libro di Norman Maclean (1992) “Young Men and Fire” per illustrare una lacuna nella nostra attuale comprensione delle organizzazioni. Due domande: perché le organizzazioni si disfano? E come si possono rendere le organizzazioni più resilienti? THE INCIDENT

When the fire was spotted, 16 smokejumpers were sent to fight it. The wind conditions that day were turbulent. The crew met ranger Jim Harrison who had been fighting the fire alone for four hours. They began to move along the south side of the gorge to surround the fire. Dodge and Harrison, after exploring further ahead, were concerned that the forest near which they had landed might be a "death trap". They told second-in-command, William Hellman, to take the crew to the north side of the gorge. At that point Dodge saw the fire at 200 meters and they began to move. Dodge created an escape fire, but no one trusted his choice. 13 people died. Dodge and the other 2 sought help and it took 450 people to put out that fire. The council felt the men would be saved if they paid attention to Dodge's efforts. Since then, the firefighters have been trained and equipped with all the necessary tools for safety. METHOD

Among the evidence sources used by Maclean to construct this case study were interviews with the 2 survivors and relatives, trace recordings, archival documents, direct observation (on-site visit with survivors), personal experience, and mathematical models. All this after 28 years after the disaster, which made it difficult to collect evidence both in terms of documentation and inaccessibility of the area. The data collected using the above sources still had gaps in understanding how exactly the race between fire and men unfolded. So, Maclean turned to mathematical modeling of how fires spread. It is the combination of the model output and subjective reports that provide the revealing timeline of the last 16 minutes. COSMOLOGY EPISODE UN MANN GULCH

The question is what should the structure of a small group be when its job is to face sudden danger and prevent disaster? This is common in the current situation because many organizations work as small, temporary teams. The group of smokejumpers can be seen as an organization because 1) they have a series of interconnected routines, 2) they have the 5 criteria of Mintzberg (1983): poorly formalized behavior, organic structure and the responsible person who tends to formulate plans intuitively 3) l Mann Gulch's crew has an interrelated role structure. The Mann Gulch tragedy indicates that small organizations are susceptible to sudden loss of meaning. People, including those who jump smoke, act as if events are coherent in time and space and that change unfolds in an orderly fashion. An episode of cosmology occurs when people suddenly and deeply feel that the universe is no longer a rational and orderly system. This is what happened: as the fire spread, the crew began to lose the structure, they became more anxious and found it more difficult to make sense of what was happening. SENSEMAKING IN MANN GULCH

According to March, “decision-making preferences are often inconsistent, unstable and externally driven; the links between decisions and actions are loosely coupled and interactive rather than linear; the past is notoriously unreliable as a guide for the present or the future; and political and symbolic considerations play a central, perhaps a priority, role in the decision-making process”. Reed wondered if that was really still the case. Three theories: sensemaking (Klein, 1993); people have replaced an interest in decision making with an interest in power; people are replacing less

appropriate normative models of rationality with more appropriate models of rationality, such as the model of contextual rationality (White, 1988). Reed (1991) has described contextual rationality as a motivated action to create and maintain institutions and traditions that express some conception of correct behavior and a good life with others. The basic idea of sensemaking is that reality is a continuous result that emerges from efforts to create order and make retrospective sense of what happens. In the case of Mann Gluch, the noise of the wind, the flames, the exploding trees, the rising temperature and many other factors caused the crew to lose sensemaking. The situation was beyond their past experience and they weren't sure what happened or who they were. ROLE STRUCTURE IN MANN GULCH

The other problem in Mann Gluch was the loss of structure. There were two episodes. The first was when Dodge told Hellman to take the crew to the north side of the gorge; this created confusion in the crew became confused. In addition, in two moments there were those who proposed to take command. This has dissolved the perception of leadership roles. The second tragic moment was when Dodge told the rest of the fleeing crew to throw away any tools they had. At that moment, the crew, abandoning their instruments, lost their identity as a firefighter and their role. So it is normal that the final command of the chief "crew" to jump into the fire escape was heard not as a legitimate order but as the delusions of someone who had gone mad. PANIC IN MANN GULCH

Panic led the crew to disintegrate. Dodge kept seeing a group and thinking about their well-being, which helped keep their fear in check. The rest of the people, however, cared less for each other. As a result, the group, as they knew it, disintegrated. This led individuals to revert to primitive flight tendencies. FROM VULNERABILITY TO RESILIENCE

The erosion of sense and structure reached its climax in the crew's refusal to escape a fire by entering another that had been intentionally set. Four sources of resilience: (1) improvisation and bricolage, (2) virtual role systems, (3) the attitude of wisdom, and (4) respectful interaction. Improvisation and bricolage when people are put under pressure, they regress to their more accustomed ways of responding. This is what we see in the 15 people who refuse Dodge's order to join him and who instead resort to flight, a more cultured trend. What we don't expect under life-threatening pressure is creativity. Dodge was a bricoleur, someone who could create order with whatever material was at hand. Bricoleurs remain creative under pressure, precisely because they routinely act in chaotic conditions and bring order out of them. If more attention was paid to improvisation in a crew person's job description, that person's receptivity and generation of role improvisations could be improved. Consequently, when an organizational order collapses, a replacement could be invented immediately. Rapid replacement of a traditional order with an improvised order would avoid paralysis. Virtual Role Systems The social construction of reality is almost impossible in the chaos of a fire, unless the social construction takes place in a person's head, where the system of roles is reconstituted and managed. Even if the Mann Gulch role system has collapsed, this type of collapse does not necessarily have to lead to disaster if the system remains intact in the individual's mind. Furthermore, people can manage the group in their head and use it for continuous guidance of their individual action. The Attitude of Wisdom

The system of roles most able to accept the reality that ignorance and knowledge grow together may be the one in which the organizational culture values wisdom (which is an attitude). Wisdom is an attitude taken by people towards the beliefs, values, knowledge, information, skills and abilities that are held, a tendency to doubt that these are necessarily true or valid and to doubt that they are an exhaustive set of those. things that could be known. This is the sense in which wisdom, which avoids extremes, improves adaptability. Respectful Interaction Respectful interaction depends on intersubjectivity (Wiley, 1988: 258), which has two distinctive characteristics: (1) intersubjectivity emerges from the exchange and synthesis of meanings between two or more communicating selves, and (2) the self or the subject is transformed during the interaction such that a joint or fused subjectivity develops. Many role systems may not change fast enough to keep up with a rapidly changing environment. The only form that can keep up is the one based on face-to-face interaction. And it is here, rather than in the routine, that we get a better look at the core of the organization. A partner facilitates social construction and is a second source of ideas. If, however, a system of roles collapses among people in whom trust, honesty and self-respect are more fully developed, new options are created, such as mutual adaptation, blind imitation of creative solutions, and confident compliance. STRUCTURES FOR RESILIENCE From the question “what should the structure of a small group be when its job is to face sudden danger and prevent disaster?” Four more questions arise. 1. What is meant by "small group"? By “small group”, in the literature, we mean any group with fewer than 10 participants. The crew is a group of 16 individuals, in which there is no communication and works with rules and supervision. It acts as if it were a large formal group. Lack of communication leads to lack of coordination. In addition, the lack of communication coupled with the fact that this is a temporary group increases the likelihood of the group breaking up. Although smoke jumpers have the ultimate goal of containing fires, their group bonds may not be sufficiently developed for this to be a group goal that overrides self-interest. 2. What is meant by "structure"? By structure we mean "a control complex characterized by the interaction that creates shared interpretative schemes: roles, rules, procedures etc. Meanings affect structures, which affect meaning. However, this game can create instability. What people needed was a structure in which there was both an inverse and direct relationship between role systems and meaning. In Mann Gulch, the role system lost its structure, which led to a loss of meaning, which led to a further loss of structure, and so on. When smoke jumpers begin to lose structure, they also lose meaning, which warns them to be more attentive to the structure they are losing, or they acquire individual meaning, which leads them to realign the structure. The second alternative may be visible in the actions taken by Dodge, Rumsey and Sallee. We find that the creation of social sense can be more stable when it is both constitutive and destructive, when it is capable of simultaneously increasing ignorance and knowledge. 3. Is "outfit" the best way to describe smoke jumpers? Smoke jumpers are tied together in large part by shared interdependence. What is significant about shared interdependence is that it can work without much cohesion (Bass, 1990: 622). And this is what may have trapped the crew. Closer ties allow for clearer thinking, which allows people to find paths around obstacles. What Smith shows is that this group of 16 forms and reforms in many different directions throughout its history, each time with a different coherent structure of people at the top, middle and bottom, each with different roles. What also becomes clear is that any attempt to identify the leader or explain survival by looking at a single set of actions is

doomed to failure because it does not reflect how needs change as a crisis unfolds, nor does it reflect how in which different coherent groupings are formed. to meet new needs. 4. there is a structure that allows people to face a sudden danger, who builds and maintains it? If we consider the a priori hierarchical structure of the team, then the Mann Gulch disaster can be understood as a dramatic failure of leadership. Smokejumper crew members did not keep each other informed of what they were doing or the reasons for their actions or the situational model they were using to generate these reasons. These multiple leadership failures can be the result of inadequate training, inadequate understanding of leadership processes....