It never ceases to amaze me how the small minded and weak tend to dominate the world of politics and government. I am convinced that these weasels who are so common in government work are constantly trying to get back at the rest of us who actually made the team in high school. I recently wrote about how difficult it is to make decisions on the fire ground. I spoke about how the mind works and how a complicated and dynamic environment like the fire ground can become very confusing very quickly. I wrote about the fact that the human mind can only handle about four or five different variables and 6 to 7 different decisions before our capacity is overcome. This is not my opinion this is the opinion of scientists and psychologists who have studied the human mind for hundreds of years. Yet today I received a note from a young man who was involved in a fire, a tragic fire, who is now being targeted by his department for disciplinary action for making what they are calling "mistakes".
I am going to attach my editorial to the bottom of this blog, but the crux of the matter is this first no one goes on the fire ground with the intention of hurting anyone ever. Second mistakes only look like mistakes in hindsight if we thought we were making a mistake at the time and we knew we could hurt someone we wouldn't do it. Third it's very easy when you're talking about a fire or after a fire is over to seem like an absolute genius because you have all the answers. But to tell you the truth I've never seen a genius on the fire ground with me. I've attached the editorial I wrote I hope you enjoy it. Please let me know what you think. And remind those in your local governments when they decide to go after somebody who was in a tremendously difficult situation and things didn't go perfectly that "if you've never been in a fight you have no business commenting on the fighters".
Is Making a Mistake a Crime
There is a growing interest in using criminal prosecution as a tool to try to improve safety in the American fire service. Improving safety is connected directly with learning especially from incidents that did not go well or resulted in tragedy. This learning is deeply connected to our number-one principle which is continuous improvement. The legal system is generally a tool for punishment. Learning and punishment are two mutually exclusive activities, we must decide if we want to punish or if we want to learn.
In accidents there is a tendency for organizations to want to protect themselves from scrutiny and responsibility. Couple this with the public’s desire to hold someone accountable, a bloodlust for a sacrificial lamb and you have the perfect storm for what really is an injustice. Holding an individual accountable for a series of systemic and organizational failures coupled with a set of highly intricate and dynamically complex relationships that resulted in some type of catastrophic failure is wrong.
Take for example the case of the USS Indianapolis on its ill-fated voyage on July 30, 1945 a night that would claim the lives of 879 sailors, forever destroy the reputation and career of an exemplary and well distinguished Capt. McVay be responsible for the suicide for his suicide 23 years later.
On 30 July 1945, the Indianapolis was hit by two torpedoes she went down in about 12 minutes. Estimates say that 900 sailors made it into the water and when they were rescued five days later only 317 have survived the exposure and the relentless attack of sharks. Capt. McVay was subsequently court-martialed for according to the Navy, failing to zigzag as was the policy when submarines were reported in the area, and failing to order evacuation of the ship in a timely manner
Because this was the greatest sea disaster in history for the Navy it quickly looked for someone to blame. Many years after Capt. McVay's conviction was the release of significant evidence which proved the captain was innocent for example the Navy never told the captain that there were submarines in the area. The Navy refused the captain's request for an escort and that without confirmed evidence of a submarine in the area the captain was under no obligation to use a zigzag pattern.
There is always a natural inclination to want to blame someone when things go wrong. We want to hold someone accountable so that we can all rest assured that the systems we are working in and the structures that we have created are safe. For years many people have said that systems keep people safe. Recently work by brilliant people like Sidney Dekker, Gary Klein and others have proven that systems to not keep us safe rather that people using their expertise and experience keep systems safe.
But in tragedies we want to find a scapegoat, a bad actor to blame because blaming makes us feel that we have achieved some level of justice. Learning requires we move away from that approach when something as complex and intricate a structural firefighting is involved. This does not vindicate people who intentionally and deliberately go out and do something wrong. This is not being written naïvely assuming that there are not evil and bad people in the world there are.
However we generally do not find evil people in public safety. There is a principle called the local rationality principle which basically states that people in public safety are all generally trying to do the very best jobs they can. This means the decisions they made at the time were based upon their experience, knowledge and best understanding of the situation. What they choose represented the very best decisions they could make to effect the situation in a positive and safe manner.
Unfortunately we are seeing this growing trend towards using the criminal justice system to try to encourage safe behavior or to try to determine accountability when a structural fire response results in tragedy. There is not a good track record for the use of criminal prosecution to effect positive change or improve safety. Rarely is it the deviant act of one person that is responsible for tragedy. Research and history have proven that most major tragic accidents and events outcome’s were rooted in systemic issues and complex interrelated activities that no one individual was solely responsible for or in fact even able to effect.
One of the major problems with assigning blame for bad decision-making is that in hindsight everything appears to be so obviously wrong. Also the more catastrophic the event the more we assume that everything that led up to it in terms of decision-making and actions taken should have been seen as flawed or inappropriate. Psychologists have shown us that we make incorrect assumptions about the amount of control people had during an event and that our knowledge of the outcome deeply affects our ability to judge or understand their performance.
So where do we go from here, one very promising concept is “storytelling”. Providing an opportunity in a non-punitive way to engage those involved in these events to tell their story. This allows the investigators who really want to learn from the event to try to match the stories of those involved in making those decisions in the moment with what we know was going on that they may have been unaware of. Story telling allows us to see how the system and those in it reacted, calibrated and understood the context of the situation without assigning blame.
We know we are driven to find the cause of events; it is fundamental to human nature. But rather than repeat the injustice done to Capt. McVay by looking for the easy way out a bad apple, a lousy captain let us look more deeply at the systems and organizational structures related to training, management, supervision, design, decision-making, authority and responsibility before we decide that our systems are safe and that one man was to blame. It's time to choose between learning and continuous improvement or punishment and closure.