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Jan 11-25, 2009:
Set up page content from archived documents and new writings about our history
About Us: The San Bernardino Group
From the county that brought you McDonalds hamburgers and the Hell's Angels
We Began by Combining Both HRO Science
and Practical HRO Experience
Pete Sarna, Public Safety Chief, Alameda County Parks and Recreation, visited us to discuss our teaching about decision making during the emergency, a piece he stated was missing from much of crisis management. This involved John Boyd’s OODA Loop, psychological biases and heuristics, Janis and Mann’s work on conflicted decision making, and physiological fear responses. He subsequently connected our group with his 
colleague Karlene Roberts, PhD, University of California, Berkeley. Dr. Roberts had previously codified specific traits from the reliability and performance of the
aircraft carrier USS Carl Vinson commanded by Admiral Thomas Mercer. This codification of Adm. Mercer's command she described as a High Reliability Organization, a naturalistic type of organization where catastrophic failure in high tempo environments is rare. Her graduate student, Carolyn Libuser, PhD, later found these same traits could improve performance in the banking industry.
At a conference on Catastrophic Risk Management hosted by Dr. Roberts at UC Berkeley we 
came into contact with other experts such as Tony Ciavarelli, Najm Meshkati,
and Tony Hare. Karl Weick, PhD, University of Michigan, described the mindfulness individuals and organizations need to manage the unexpected through anticipation and containment.
Bert Slagmolen, PhD, brought an international connection to our group after joining us with his
work in High Performance Systems (HPOs) which work in systems where service is the failure rather than death. We continue a close and continuous relationship with him and his group, Apollo13: Managing the Unexpected, with regular visits between us and our joint publications.
We have continued our association with these academicians to ensure that science informs our practical approach to problem solving in uncertainty.
"Other people's stories are what make us strong." Tony Hare, PhD
Group Members
Medical Profession Members
Van Stralen, David, MD, FAAP, is an Assistant Professor of Pediatrics and a pediatric critical care physician on staff at Loma Linda 
University Children’s Hospital and Children’s Subacute Center at Community Hospital of San 
Bernardino (California), Adjunct Professor of Emergency Medical Service at Crafton Hills College, Yucaipa, California, and medical director for American Medical Response, San Bernardino County. He served as Medical Director for San Bernardino County Fire Department (covering 20,000 square miles) for ten years. He worked in South Los Angeles as an ambulance man and fire department rescue ambulance driver for the Los Angeles City Fire Department in the 1970s. By one review, he is the first career paramedic to attend medical school. He has a Bachelor of Arts in Social Ecology and a Bachelor of Science in Biological Science from the University of California, Irvine; an MD degree from University of California at Irvine College of Medicine where he completed his Pediatric Residency. He completed a Pediatric Critical Care Fellowship at Children’s Medical Center and Parkland Memorial Hospital, Dallas, Texas. At Loma Linda University he worked with another Pediatric Intensivist, a Viet Nam combat veteran (Navy A-4 pilot), to create a High Reliability Pediatric Intensive Care Unit. He also developed the pediatric critical care transport service and the nation’s first clinical academic Emergency Medical Care baccalaureate degree for paramedics. Using a fire service/EMS model with critical care principles he developed a subacute care model for profoundly handicapped children that enabled them to play and develop despite dependency on mechanical ventilation for life while cared for in a chronic intensive care unit. He collaborates with safety, risk, and reliability experts from wildland firefighting, business, and healthcare in the US and Europe to identify common approaches the individual uses to ensure safety and reliability.
Johnson, Febra, RD CNSD, Clinical Dietitian Manager, Loma Linda University Medical Center & 
Children's Hospital
Febra Johnson, RD, CNSD, is the Clinical Pediatric Dietitian Manager for Loma Linda University Children’s Hospital, Loma Linda, California. She received her Bachelors of Science degree in Dietetics from Andrews University, Berrien Springs, Michigan. Ms. Johnson uses high reliability theory in management and for nutrition services for children with chronic or critical illnesses. Her early exposure to high reliability theory was in the pediatric intensive care unit.
Thomas, Dywane C. A.S. in Respiratory Therapy, Corona Regional Medical Center, Corona, Ca
Chief Warrant Officer 3, U.S. Marine Corps, Retired
Dwayne C. Thomas is currently a Respiratory Care Practitioner working in the state of California. He received his AS in Respiratory Care from Concorde Career College (San Bernardino, Ca). He provides respiratory therapy which includes assessment, treatment, and management within the critical care hospital environment. This also includes providing consultation, instruction, and/or technical direction to medical, nursing, and other staff members during medical emergencies.
He retired from the United States Marine Corps as a Chief Warrant Officer 3, with over 20 years of active service. During his career he was introduced to High Reliability Organization principles via John Boyd's OODA Loop, which he used in the support and training of Marines. His most recent position with the Marine Corps was as the Director, I Marine Expeditionary Force, Headquarters Group, Group Personnel Administrative Center at Camp Pendleton, CA.
Racquel Calderon, BS RRCP, Director of Respiratory Services, TK
Ms. Calderon is Director of Respiratory Services, Totally Kids Specialty HealthCare. She uses the principles of High Reliability Organizing to develop a freestanding pediatric subacute care facility (with four home mechanical ventilators) into a chronic intensive care facility (with 45 ICU-level mechanical ventilators). She uses HRO to give simultaneous delivery of high risk respiratory care with growth and development for profoundly handicapped children (a child’s smile is the end-point of ventilator management). She received her AS in Respiratory Care from Crafton Hills College (Yucaipa, CA), an AS in Cardiopulmonary Sciences from School of Allied Health Professions, Loma Linda University, and her BS in Business from the University of Redlands, Redlands, California.
Jim Holbrook, Ed.D., is Professor of Emergency Services, Crafton Hills College (Yucaipa, CA) 
and Adjunct Professor of Emergency Medical Care, School of Allied Health Professions, Loma Linda University. His research is in decision-making under stress and use of brain-based behaviors in paramedic education. He earned his paramedic certification from Loma Linda University, his Bachelor of Vocational Education and MA in education from California State University, San Bernardino, and his Doctorate in Education from Nova Southeastern University, Ft. Lauderdale, Florida.
Jeff Lewis, LVN, LNHA, MA, Vice President Kosair Charities Pediatric Convalescent Center
Jeff F. Lewis is a Licensed Vocational Nurse and a Licensed Nursing Home Administrator in the states of California and Kentucky. His Master of Arts in Counselor Education is from California State University, San Bernardino (CA), and His Bachelor of Arts is from Oakwood College, Huntsville, Alabama. Since 1993 he has worked in administration and management of health care facilities with experience in program development, strategic planning, administration, budgeting, and leadership management. He began the study of High Reliability Organizing (HRO) for use in healthcare facilities in 2000 presenting with his team HRO applications to subacute nursing home care at a research conference in Lyon, France and an HRO conference in Deauville, Normandy, France. He has identified the high risk character of the nursing home environment as one that benefits from HRO and continues to use this methodology in his leadership capacity at Home of the Innocents in Kentucky
Firefighting Profession Members
Provansal, Gary, Division Chief, San Bernardino County Fire Department (Structure and 
Wildland Fire, EMS, Disaster Response)
Gary Provansal, Division Chief, Special Operations, San Bernardino County (CA) Fire Department, is responsible for counter-terrorism, Emergency Medical Services, Urban Search and Rescue, Hazardous Materials, and training for the county fire department that covers 20,000 square miles, the largest county in the United States. He serves on the Joint County Terrorism Oversight Committee for Riverside and San Bernardino Counties. He also administers the Federal Aviations Administration’s (FAA) Western Region Air Crash Rescue Training School. He served on a Federal advisory group for counter-terrorism training for the national fire service. He represents San Bernardino County for the low-level nuclear waste program for the US Department of Energy (DOE). He was the Director of the San Bernardino County Emergency Operations Center for the fire siege of 2003 where, with a staff of 500, he directed the evacuation of 155,000 citizens from mountain communities and several hospitals. He also acted as Operations Chief for the Emergency Operations Center (EOC) during the subsequent floods that killed 14 people. He started his career with the department as a firefighter and paramedic.
James "Jim" Patrick Denney, MA, Capt. LAFD and OSS Group (founding member) EMS, Disaster and Terrorism Response (1947-2006). He served on staff with Louisiana State University, National Center for Biomedical Research and Training and the Academy of Counter-terrorism. He was a member of the Department of Defense, Defense Science Board (DSB) Civil Integration and Response Panel for Terrorism and Transnational Threats. He was also an Advisor to the Defense Advanced Research Project Agency (DARPA) ENCOMPASS program, the Defense Science Research Council (DSRC) and the RAND Advisory Panel to Assess Domestic Response Capabilities for Terrorism Involving Weapons of Mass Destruction. He has served on numerous local, state, and national committees for Emergency Medical Services and disaster. He retired with the rank of Captain from the Los Angeles City Fire Department where he served during the riots in South Los Angeles and two major earthquakes. He retired as an EMS District Commander and Department Paramedic Coordinator. He served with the US Navy Seabees with two tours in Viet Nam, one in a high combat area. He also served as a Deputy for the Los Angeles County Sheriff’s Department. He received his BA in Business and an MS in Health from Emerson College, Ontario, Canada.
Joe Martin, Battalion Chief (ret.), Los Angeles Fire Department, served 30 years in the Fire Service and Emergency Medical Service (EMS) including paramedic service. He has experience in several disasters (EMS supervisor for the first 24 hours of the Los Angeles riots, the Northridge Earthquake, and in strike teams during the Southern California Fire Storms). He has also managed or participated in more than 30 large scale multiple casualty incidents of greater than 20 victims. With LAFD he served as Quality Improvement officer, training officer for new paramedics, drill master and recruit training chief. He also assisted in development of the airborne (helicopter) rescue teams. The last 13 years with the fire service he based his approach on a high reliability model. He was also principal in a company that provided civilian corporations with emergency and disaster training. He is a former pararescue technician for the US Air Force where his duties included standby for the Apollo space program launches.
HRO International Consultant Member
Slagmolen, Bert, PhD is Managing Partner of a Dutch consultancy firm, IME organization consultants and Apollo13: Managing the Unexpected
IME works primarily for governmental, not-for-profit and professional organizations in the Netherlands. One of his focus areas is High Performance Organizations and the implementation of intervention strategies to make organizations more reliable, more client-oriented and more professional. He studied electronics at the Technical University in Delft and business administration at the Erasmus University in Rotterdam. He finished his PhD on the Analyses of ICT-narratives in organizations and society. He currently consults for Dutch ProRail, the Dutch national rail infrastructure manager, and for the Dutch Labor Offices.
HRO Researcher Member
Roberts, Karlene, PhD
is Professor at the Haas School of Business, University of California, Berkeley. She is also Director of the Center for 
Catastrophic Risk Management at Berkeley. For the last twenty years her research has been on the design and management of high reliability organizations (HROs). HROs are organizations in which errors can have catastrophic consequences, but which are managed so well that errors infrequently occur. Two of her recent publications are “Designing for High Reliability: The Birth and Evolution of a Pediatric Intensive Care Unit.” Organization Science (2006) 17, 239-248. (with Peter Madsen, Vinit Desai, and Daniel Wong) (Winner of the Emerald Management Citation of Excellence, 2006); and “Reinventing Flood Control” Tulane Law Review, (2007) 81, (with Daniel Farber, Robert Bea, Edward Wenk, and Kofi Inkabi). She has been on a number of National Research Council (NRC) and National Science Foundation (NSF) committees and panels. She is currently a member of the Association of Space Explorers panel on Earth Vulnerability to Near Earth Objects (asteroids). She consults with a number of U.S. federal agencies and industries.
Robert Bea, PhD., is a professor in the Department of Civil & Environmental Engineering, 
Engineering and Project Management Group, at the University of California, Berkeley. He began his engineering career with the U.S. Army Corps of Engineers in 1954. He then worked for Shell Oil, Shell Development, and Royal Dutch Shell companies in a variety of engineering, construction, operations, and research assignments around the world. In 1977, helped found the Ocean Services Division of Woodward-Clyde Consultants where he became Chief Engineer and Vice President of the company. In 1981, he helped found the Ocean Engineering Division of PMB - Bechtel where he became Senior International Consultant and Vice President. These companies provided integrated ocean engineering and contracting services for a wide variety of companies and governments around the globe. He was appointed to the faculty of the University of California Berkeley in 1989. His experience includes design of structures and foundations (fixed and floating platforms, pipelines), construction (welder, concrete worker, carpenter, superintendent, inspector), operations (drilling, production, exploration), maintenance (inspections, repairs), and management (engineering, operations, research & development) in assignments in more than 60 locations around the world (lived in 13 different countries). Since his appointment to the University of California Berkeley, his research and teaching have focused on risk assessment and management of engineered systems with specialization on human and organizational factors, criteria and guidelines for design and requalification, and margins of quality (factors of safety).
HRO Advocates Also Associated With This Group
Anthony "Tony" Hare, PhD, is a forensic clinician with the San Francisco Forensic Institute. He served for 24 years with the Oakland Police Department where he retired as a Captain of Police. He served as incident commander at numerous critical incidents in Oakland including crime scenes and natural disasters. His experience as a crisis/hostage negotiator and leader of the Hostage Negotiation Team led to his guidelines for heedful innovation in challenging incidents that do not respond to traditional techniques. The U.S. Army, the U.S. Department of State, London Metropolitan Police, and other law enforcement agencies around the world have adopted these principles. Dr. Hare is a retired lieutenant colonel, U.S. Army Reserve who served as an Infantry commander in Vietnam, as aide-de-camp to the Chief of Staff, U.S. Army Vietnam, and in Operation Desert Shield/Desert Storm. He is a visiting scholar with the Center for Catastrophic Risk Management (CCRM) at the University of California at Berkeley. He has published articles on crisis negotiation and critical incident management in military and civilian journals and texts and in a report to the U.S. Congress. Dr. Hare has a Bachelor of Arts in Psychology from the University of California at Berkeley, a Masters in Science in Counseling from California State University, Hayward, and a Masters of Science in Psychology and a Doctor of Psychology from Wright Institute in Berkeley.
Dennis M. Kowal, PhD, Colonel (ret.) is an analyst for the Institute for Defense Analysis where he conducts research for the Department of Defense in a variety of areas that include human factors assessment of enhanced human performance technology to the development of strategies to assess intentions of terrorist groups. Before that he was command Psychologist for a Special Mission Unit and the US Army Intelligence Command at Ft. Belvoir, VA. He has conducted training in negotiation strategies, conflict resolution, stress operations, and remote profiling of target individuals. He co-authored a study of the “at risk” factors of individual’s who committed espionage against the US during the 1980s, and the NRC recently published his article entitled: “The Insider Threat.” Kowal received his BS in Psychology from the University of California, Santa Barbara, his MA in Physiological Psychology from California State University, San Jose, and his PhD in Physiological Psychology from The Claremont University, Claremont, California. He received further clinical training at Boston University and a post-doctoral residency in neuropsychological assessment at Walter Reed Medical Center and Georgetown University Medical School, Washington, DC.
Bruce Spurlock, President and CEO of Convergence Health Consulting, Inc. and the executive 
director of Beacon - The Bay Area Patient Safety Collaborative. He also is an Adjunct Associate Professor at Stanford University.
Marc H.P. Otten, Royal Fire Academy, The Netherlands
Luc JORDA, Colonel, Director, Firefighting Academy and Departmental Director of Firefighters of the Bouches du Rhône SDIS 13, the southern region of France's emergency response organization. He leads 1200 professional and 3500 volunteer firefighters. Together they face every kind of risk: flooding, hazardous materials, high angle rescue, scuba diving response, confined space rescue, extrication, building fires, Basic Life Support/Advanced Life Support and of course forest fires.
Michele M. Zembo, MD, MBA, is an Associate Professor of Orthopaedic Surgery at Tulane University School of Medicine. She is the Director of the Medical Staff and Graduate Medical Education at the Medical Center of Louisiana at New Orleans. She is currently charged with developing a comprehensive Quality and Safety Program for the School of Medicine and the Tulane Medical Center. She was Director of Compliance for the Louisiana State University School of Medicine and their Faculty Group Practice for eight years. She is a founding Board Member of the Louisiana Emergency Response Network (LERN). The LERN Board is responsible for developing a statewide system to facilitate the treatment of trauma and time sensitive illnesses. She is an active member of the American Academy of Orthopaedic Surgeons having served on numerous committees and is currently a mentor in the Leadership Fellows Program. She has spoken nationally on a variety of topics including pediatric orthopaedic surgery, healthcare compliance, practice management, and health information technology. She received her Bachelor of Science in Biology from Rensselaer Polytechnic Institute, her MD from Penn State College of Medicine, and her Master in Business Administration from the University of New Orleans. She completed her orthopaedic training at the University of Michigan and her fellowship in pediatric orthopaedic surgery at Louisiana State University.
HRO Resources Also Associated With This Group
W. Earl Carnes, BS, MA. Is a Senior Advisor for High Reliability for the U.S. Department of Energy (DOE) and also serves as the DOE liaison with the Institute of 
Nuclear Power Operations (INPO). His principal function is to support the DOE Research and Development, Environmental and Defense missions with improving performance and safety through adopting HRO principles and practices. Mr. Carnes coordinates with other U.S. federal government agencies, international agencies, industry and the academic community on HRO application. Prior to joining DOE Mr. Carnes worked as a management consultant and with INPO as a specialist in emergency management. His academic work includes a Bachelor of Science in Chemistry, a Masters of Arts in Communications and additional graduate studies in Systems Engineering focusing on the management of scientific and technical knowledge.
Christopher Hart,
Christopher A. Hart was sworn in as a Member of the National Transportation Safety Board on August 12, 2009 and designated by the President for a two-year term as Vice Chairman of the Board on August 18. Member Hart joined the Board after a long career in transportation safety, including a previous term as a Member of the NTSB. Immediately before returning to the Board, Member Hart was Deputy Director for Air Traffic Safety Oversight at the Federal Aviation Administration. He was previously the FAA Assistant Administrator for the Office of System Safety.
He served as a Member of the NTSB from 1990 to 1993. After leaving the Board, he served as Deputy Administrator of the National Highway Traffic Safety Administration, before moving to the FAA in 1995.
From 1973 until joining the Board in 1990, Member Hart held a series of legal positions, mostly in the private sector. He holds a law degree from Harvard University and Master’s and Bachelor’s degrees in Aerospace Engineering from Princeton University. He is a member of the District of Columbia Bar and the Lawyer-Pilots Bar Association.
Member Hart is a licensed pilot with commercial, multi-engine and instrument ratings. Member Hart’s family has a tradition of accomplishment in the field of transportation. His great uncle, James Herman Banning, was the first African-American to receive a pilot’s license issued by the United States government, in 1926.
His term expires December 31, 2012.
Anthony Ciavarelli, PhD. 
received his doctorate degree from the University of Southern California in Education, in 1988, and a Masters Degree in Experimental Psychology from the California State University in 1976. He is a Research Professor for the Modeling Virtual Environment and Simulation (MOVES) Institute at the Naval Postgraduate School in Monterey California, and the founder of Human Factors Associates, Inc. Over a 40-year career, he has developed systematic methods to develop, validate, and apply quantitative and qualitative measures of effectiveness in real-world operational environments. His professional experience includes the design of military and civilian training systems and the development of performance measurement methods used in the assessment of educational and training effectiveness. For the past few years he also has worked on the development and validation of organizational effectiveness measures that address organizational climate and risk culture. Prior to joining the Naval Postgraduate School in 1989, Dr. Ciavarelli had over twenty years experience in Aerospace and Defense Industries, where he served as a R&D product manager, human factors engineer and scientist working to improve individual and team performance. Dr. Ciavarelli founded Human Factors Associates, Inc., and successfully brought his work in aviation safety to the civilian aviation, aerospace and medical service industries by offering online (Web-based) assessment and human factors consultations directed at improving risk performance and organizational reliability.
Dan Kleinman,
Operations Section Chief,
National Incident Management Organization,
Fire and Aviation, Washington Office
Dan has 35 years of wildland fire and all hazards experience. His experience includes Engines, Fire Prevention, Fuels Management, and Hotshots. He was a member of the Fulton Hotshots for 13 years with 8 years as Superintendent, was promoted to Battalion Chief (AFMO) in 1995, Division Chief (DFMO) in 2000, and NIMO Operation Section Chief in August of 2006. He has been actively involved with Incident Management Teams in the positions of Division/Group Supervisor, Operations Branch Director, Operations Section Chief, and Incident Commander since 1990. Complex incident management experience includes many wildland fires, several missions of national significance including the 9/11 attack on the Pentagon, Columbia Shuttle Recovery, Greensburg Kansas Tornado, and four Hurricanes. Dan also performed as an Operations Section Chief Type 1 on wildfires in Australia in 2007. During his career, he has been actively involved as an instructor in wildland fire suppression, incident management, and leadership. Currently he is a member of the NWCG Leadership Committee working on the development and delivery of Advanced Leadership programs. He is a student of High Reliability Organizations, Human Factors, Decision Making, and Leadership Development.
Christenson, David, MA Acting Center Manager, U.S.
Widland Fire Lessons Learned 
Center,National Advanced Fire & Ressource Institute
David Christenson has been the Assistant Center Manager of the U.S. Wildland Fire Lessons Learned Center since 2002. He has focused on promoting organizational learning, implementing high reliability organizing, and creating a widely used knowledge management system for the nation’s wildland fire community. He coaches incident management teams on practical HRO implementation and is a co-chair of the French/USA HRO in IMTs Project. He has given presentations in Sweden, Norway, Spain, Greece and France in addition to the U.S. on these subjects. He earned a Masters of Applied Geography with honors from New Mexico State University in 2000 after a career in the US Air Force developing teams working with jet fighter aircraft. He began working with HRO while assigned as the NCOIC of the Quick Reaction Alert Interceptor Force at Soesterberg AB, Holland in 1980. While working full time on his masters, he was also a full-time conservationist specializing in remote sensing and GIS analysis. That position was co-sponsored by both the USDA’s Natural Resources Conservation Service and the research division of the National Agricultural Statistics Service. Before working in wildland fire with the US Forest Service, he was a national program manager for a private sector spatial decision support systems development firm.
Honorable Mention
Kathleen Sutcliffe, PhD, is Professor of Management and Organization at the University of
Michigan Ross School of Business. Her research is concerned with organizational reliability and she is currently examining medical mishaps and errors. She is the co- author (with Karl Weick) of Managing the Unexpected: Assuring High Performance in an Age of Complexity. Sutcliffe holds a BA in Education from the University of Michigan, a BS in Nursing from the University of Alaska, an MSN from the University of Washington, and a PhD in Management from the University of Texas, Austin.
Karl E. Weick, PhD is the Rensis Likert Distinguished University Professor of Organizational Behavior and Psychology at the University of Michigan Ross School of Business. His research interests include sensemaking under pressure, medical error, hand offs in extreme events, high reliability performance, improvisation, and continuous change. He is co author (with Kathleen Sutcliffe) of Managing the Unexpected: Assuring High Performance in an Age of Complexity. Weick received his BA at Whittenberg College and his MA and PhD at Ohio State University.
Thomas A. Mercer, MS, Rear Admiral (ret.) was Superintendent of the Naval Postgraduate 
School at Monterey, California. He was also Executive Director of the Center for Risk Mitigation at the University of California, Berkeley. Before that he was on the Joint Chief’s Staff for interoperability, strategy, connectivity and operational planning. Mercer received BS from the U.S. Naval Academy and his MSAE from the Naval Postgraduate School. He also graduated from the Navy’s nuclear propulsion school. Mercer was an A-7 carrier pilot.
Peter C. Sarna, MA, BA, Capt. (ret), Oakland Police Department, is co-principal of the Chief Executive’s Group, a public safety consulting firm. Prior to this he served as Assistant General Manager for Public safety for the Oakland Regional Park System, the nation’s largest regional park. Sarna’s BA is from American International College (cum laude) and his MA in Sociology is from Boston College.
"For the purpose of authorship, unless otherwise noted Daved van Stralen is the principal author."
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