Complexity and Control
This story is from Weick and Sutcliﬀe’s book, Managing the Unexpected: Resilient performance in an age of uncertainty (2007, pp. 3-8):
The Cerro Grande ﬁre in New Mexico in May, 2000 originated as a prescribed burn, intended to reduce the severity of potential ﬁres by eliminating sources of fuel. What went wrong? The conditions on the ground were miscalculated, which led to a smaller detachment of ﬁreﬁghters being deployed and other small deviations from normal practices used to contain prescribed ﬁres. The ﬁre was started later in the day than planned, which meant that the crew was exhausted rather than fresh when matters began to go south. Part of the ﬁreﬁghting crew was kept on duty longer than usual, which further diminished its eﬀectiveness at noticing small events at the edge of containment. The ﬁrst burn boss was unable to convince dispatchers to send a relief crew as soon as it was needed, because dispatchers deferred to authority rather than to the ﬁre boss’ expertise. They required him to wait until their supervisor came on duty. But when the supervisor came on duty, an argument ensued about who was to pay for the relief crew and whether the ﬁre ﬁt the technical standards necessary to warrant another crew. Although the crew was eventually deployed, it arrived at least three hours after it was needed and the helicopter sent to reinforce ﬁreﬁghting eﬀorts arrived late, with no water bucket.