The Collapse of Sensemaking in Organization: The Mann Gulch Disaster, Case Study Example

Introduction

The essay will look at three communications problems that existed during the Mann Gulch disaster on August 5, 1949, in which 13 men died. Use will be made of the technical literature available to analyze the problems identified and unearth remedies which should serve as points of reference for future engagements, where they may become necessary.

Analysis

Three communication problems identified during the reading of the Mann Gulch Disaster were a breakdown in role structure, a sudden loss of Sensemaking, and the development of cosmological episodes.

Role Structure

The crew that arrived at Mann Gulch fits Wesley (1990) definition of an organization, in that it had a series of interlocking routines, habituated action patterns around the same activity at the  same times and places they are summoned to extinguish fires (Wesley, F.R., 1990).

They also fitted well into Mintzberg five categories for a simple organization, because Jim Wagner was initially at the head giving direct supervision, the strategy would come from him, little formalized behavior was evident, the structure was not inflexible, , and the leadership was an extension of the personality of the leader (Wieck, K.E., 1990).

However, a number of events took place and caused a breakdown in the role structure that was designated to the team.

1. They team lost one of its member prior to jumping
2. The leader vacate his position to have lunch when they arrived
3. The y were assigned a new leader who was more adept at implementing orders than giving them
4. There was no one who was at the front giving structured orders they could easily understood and follow

All these events impacted negatively on their role structures as they fought the fires on the North side of the Mann Gulch area, and the sudden emergence of Joe Wagner to take over the leadership, was not welcomed, because they didn’t recognize him, as he had deserted them and lost his moral authority as well as legitimacy for the job.

In their state of minds they were not prepared to drop their tools and lie in the fire escape constructed by Joe Wagner, when he showed them the fire coming from the opposite direction, and told them it would overtake and kill them, if his directions were not followed.

Wagner was communicating, but his audience was not listening, because they had lost the sense of what they were there to do, and was running for their lives. This scenario was created when the leader at the outset left the group.  He robbed them of the opportunity to maintain their focus on specific roles, and could not regain it when he attempted to do so, because it had disintegrated beyond repair, and caused everyone to resort to look about their personal salvation.

Remedy

Had Dodge taken responsibility of the group at the outset, he would not have lost the authority and legitimacy necessary to keep the group in the role structure designed for their success.  According to Weick (1993), improvisation and bricolage is one of the ways organizations can show resilience in the face of threats to break up its structure (Weick, K.W.1993).

The presence of Dodge with the crew at the start would have led them to possible accepting his improvised safety recommendations and save their lives, because he had unknowingly embraced Bruners (1983) definition of creativity, which was figuring out how to use what you have already know, in order to go beyond what you currently think (Bruners, J.) .

He knew that he could not outrun the fire, but designed a way to get beyond what the group was thinking. Had all the members cooperated with him, the outcome would have been different. However, the breakdown of the role structure of the group was all part and parcel of his poor leadership quality in the beginning.

Sudden Loss of Sensemaking

The basic idea of Sensemaking according to Weick (1993) is that reality is an ongoing accomplishment that emerges from efforts to create order, and make sense retrospectively from what had occurred (Weick, 1993).

The crew arrived at the sight of the fire with certain expectations but what they experienced was different. According to Weick (1993), the fire they were seeing was certainly not a 10.00, and Wagner did not make it look serious by taking lunch at the moment they arrived. Additionally the flame in the south was treated as if it was not important, and the makeshift leader did not seem to have the confidence necessary to lead them based on the confusing orders he was giving.

Event by event were not adding up, and things reached a climax when  a new leader they thought had abandoned them, emerged, and was telling them to do the opposite of what they were trained to do- that is to drop their tools, and lie in the fire escape created.

Their abilities to make sense fell to very low levels, and caused them to run for their lives. Wagner could not communicate beyond the communication barriers he had created, and as such, was incapable of saving the crew.  According to Wieck (1993), the smoke jumpers were outstripped by their past experiences, and were not sure what was up, or who they were, and there was no time to decide on those issues, so the best thing to do was for them to run for their lives Weick, K.E., 1993).

Remedy

The situation could have been prevented, if the team was trained to fight more than one type of fires, briefed on arrival by the leader, provided with food and their gears at the same time, and then moved as a team towards the real source of threat in terms of the fire.

In terms of training, the composition of the team (forestry students and former military personnel) made it ideal for them to be trained in Virtual Role Systems. According to Schutz (1961), when each individual in a crew mentally takes all the roles, and therefore registers escape routes, acknowledge commands, and facilitate coordination, each will literally become a group  within a group (Schutz, 1961).

With this type of training, it would have been difficult for the role structure to disintegrate in the manner it did, because wherever a vacancy developed, each group member will be trained to fill it, and continue to maintain the order necessary to accomplish the task (Weick, K.E., 1993).

The fact that the scenarios were constantly changing, would not  have affected the team,  because they expected it, and had even the escape routes in their heads, so that when they are told to drop their tools, and lie in the fire escape, they would have acknowledged the  command, and  in the end saved their own lives.

This strategy has been supported by Weick and Roberts (1993), who both conducted a survey on accidents in flight operations of nuclear carriers. They found that those who avoided accidents were living by the credo that they will never get into situations where they have no escape routes planned (Weick, Roberts, 1993).

Cosmological Episodes

Cosmology from a psychological perspective and subsumed under metaphysics according to Weick (1993), is the ultimate macro orientation that is directed at time, space, change and contingency, as it relate to the origin and structure of the universe (Weick, K.E., 1993).

In terms of the smoke jumpers, they expect events to unfold in an orderly manner with respect to time, and space. However, when the events they experienced were different from what they expected, cosmological episodes occurred.

Weick (1993), described Cosmological Episodes as occurring when people suddenly feel that the universe is no longer orderly and rational, and when this happens, both the sense of what is happening and the means to rebuild collapses simultaneously (Weick, K.W., 1993).

The smoke jumpers no doubt have felt like the way things was unfolding in their environment was not in the order they were trained to expect, especially from a Sensemaking perspective, and ran for their lives.

Unfortunately, they could not make sense of the one act that could have saved their lives, but the communicator had no legitimacy, and could not be trusted during the types of cosmological episodes they were experiencing.

Remedy

It seems that the smoke jumpers were only trained to fight 10.00 fires, and this was a mistake that if it was corrected, would have enabled them, to face the Mann Gulch fire with more confidence.

According to Meacham (1983), reality backs up while it is being approached by those seeking to understand it, and knowledge and ignorance grows together (Meacham, J.A., 1983). He argues that the more one learns about a domain, the greater the amount of doubts, uncertainties and complexities that may arise (Meacham, J.A., 1983).

The best way the situation could have been remedied would be to embrace the attitude of wisdom regarding the fighting of the fire. Having no knowledge of other fires should not have meant that they couldn’t learn on the job to fight this one. They could have embrace the fact that knowledge and ignorance prevailed in their atmosphere, but jointly they would used what they know to decide what strategies to use fight the fire, when to use the safety escape or should they seek any other available options.

The Attitude of Wisdom according to Weick (1993) would ensure that they display the right attitude towards the fire, in that mentally they would be between being cautious and being overconfident, and would therefore make good judgment regarding their safety (Weick, K.E., 1993).

Reference

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