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Here is my January editorial it's interesting because I wrote it about three months ago. It is somewhat timely given our recent tragedy in Chicago. Fortunately I know the Chicago Fire Department very well and I know that they were very prepared and will conduct a very thorough and very complete investigation. But I guess the question is for the rest of us, are we ready if something catastrophic should happen within our departments or would we be looking for outside help and outside answers? I am not saying that outside help can not be beneficial it certainly can be but we should lead these processes from inside our organizations whenever possible.

Let me know what you think, and remember to sign up for the courage and valor FDIC fun run!

There But for the Grace of God


Jan 1, 2011

 

BY BOBBY HALTON

 

Reporter Glenn Smith from the Charleston Post and Courier has extensively covered the Sofa Super Store fire and recently wrote a column based on e-mails among members of the team hired and paid $284,000 to investigate the causes of the tragedy that occurred on June 18, 2007. The column is fascinating to read for many reasons and is available online. It has generated a flood of calls and conversations regarding how we should investigate incidents and who should conduct the investigations.

 

The opening lines of the article reveal how the team of investigators initially felt, emotionally, regarding the event: “Almost from the outset of their investigation three years ago, a group of experts concluded that Charleston’s Fire Department was a mess and that its chief needed to go for the organization to rise from ‘the dark ages.’ ”

 

This is a totally understandable reaction to a tragedy and does not, as many have suggested, confirm that the team consisted of “carpetbaggers” on a vendetta. Some point to the eagerness of some to participate: “Routley said he had been studying aerial photos of the fire site and could be en route to Charleston in a couple of hours, if needed.” The carpetbagger characterization is flawed; these are honorable men. As a matter of fact, according to Smith, these men refuse to take money for their speaking appearances associated with their work on the panel, which is noble and deserves recognition.

 

Being frustrated or angry after a tragedy is a perfectly normal human reaction; what is more important is whether the team members were able to recognize their hindsight biases and be objective in the investigation. Some e-mails revealed the team’s feelings that a leadership change was necessary to allow the department to learn and advance. This again is a very common and understandable reaction but one that has recently been challenged by one of the leading voices among human error researchers, Professor Sidney Dekker.

 

I steadfastly believe the panel was honorable and well-intentioned in every aspect of their work for the City of Charleston. These men set out to do the best possible job they could, given their knowledge, training, and experiences. But, just as Charleston and every other fire organization in the world can always improve, we can improve at how we do our investigations, reviews, and corrections when incidents occur.

 

Investigations require three components: chronological (when and where); epidemiological (causes and links); and, to be complete, a systemic component (larger picture). The most important questions we should ask ourselves are, How would we handle an investigation of a critical event should one happen in our own organization? What have we learned from the sacrifices of the Charleston nine? What will our organization do if we experience a tragedy?

 

Current leading research by Dekker recommends the following four steps to improve safety through incident investigations: First, improve the relationships between supervisors and practitioners, between chiefs and line firefighters. Work on trust and communication directly and honestly, and define the difference between responsibility and accountability. Firing, fining, or suspending someone is not accountability; having them participate in developing measures to improve and mitigate a possible future incident is. We must accept that incidents and failures are opportunities to learn, not punish.

 

To learn we must stop vilifying the participants in an incident; we must do everything we can as an organization and as a service to recognize that, given the knowledge and understanding they had of the event at the time, the actions they took were what they honestly believed to be the best options. When we condemn the participants, we condemn—by extension—the organization.

 

Establish a debriefing program within your organization now. It helps reinforce the understanding that incidents are a normal result of firefighting and emergency responses.

 

Build a safety department that is not part of the line response but which deals with incidents. When conducting an incident review, be extremely aware that it should not be a performance review. The safety department must protect the rights of the firefighters involved.

 

Begin incident reviews in recruit training. This demonstrates the organization’s commitment to learning and that incidents are not shameful. The difference between safe and unsafe organizations is not in how many incidents they have but how they deal with the ones reported.

 

Second, decide now who is going to conduct your reviews and how they are going to include the firefighters involved in the incident. Establishing a review procedure now will reassure community leaders that you have anticipated such possibilities and are ready to deal with them. By including those involved and empowering them in the aftermath, you maintain morale, maximize learning, and reinforce your organization’s commitment to continuous improvement and real learning.

 

Third, protect your organization’s information from undue outside probing. Establish that your organization has a clear procedure and an organized, trained group of investigators. This establishes that you will take the appropriate actions to learn and hopefully prevent future similar incidents. This does not mean you hide or obstruct anyone with a lawful or reasonable right to the information but that you manage your information professionally and responsibly so the irresponsible cannot use it to embarrass or defame those involved or the organization.

 

Fourth, the fire service must do better nationally in our incident reviews. We should empower and include more local involvement. We should demonstrate that we do enforce and promote internal professional discipline and that local solutions integrate local expertise. The world is always watching. It is not if but when you will have an incident. You can manage your reactions and the world’s reactions, but you have to accept that incidents will happen. Not being ready when they do is the greatest failure.

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Comment by Bobby Halton on January 28, 2011 at 1:24pm

Chris,
Thank you for the very thoughtful comments, and rest assured that this editorial was a very brief treatment of Prof. Dekkers work. There are three books by Prof. Dekker which contain much more depth, specificity and nuance regarding this topic. The first is 10 Questions to Ask, the second is Human Error Accident Investigation  Analysis and the third is Just Culture. Interestingly enough Just Culture was the book that Chessie Sullenberger was reading during the time that he participated in famous landing on the Hudson River.

As I'm sure you would agree anything worthwhile is never easy, and building a reliable and effective incident  evaluation system is going to require educating our membership about how to conduct such activities. This will take time practice and we will come up short but eventually I think we will do a much better job of reviewing our critical incidents.

 I did not intend to say that no one should ever be held accountable for the willful and intentional misconduct or failure. Clearly there will always be evil men/women and disreputable men/women who will create situations by their actions that cause harm. Those persons should be held accountable.

The group of people I was referencing is one that are generally referred to as those of us involved in"local rationale" this applies to law enforcement, fire, airline and other industries which can be considered high risk. The theory implies that the vast majority, if not all, apply the best possible practices that they are aware of, make the best possible decisions they can during the execution of their duties given their level of training, their level of expertise, their knowledge of the situation and the goals that they are pursuing. These folks should not be demonized, when a failure occurs despite their best efforts.

I truly enjoyed your response it was very well-crafted and very thoughtful please feel free to write more on the fire service I would be extremely interested in hearing your points of view as I am sure everyone else would agree.
Respectfully yours Bobby

 

Comment by Chris Fleming on January 26, 2011 at 10:08am

 You make some excellent points and my comments here have nothing to do with any specific department's review process. The fact that reviews are taking place at all is very positive to the Fire Service as a whole, and looking to experts in the field of human error research is an excellent way to create a process to prevent repeat events.   However, Dekker's recommendations seem slightly simplistic on some level.  His first recommendation of "Improve relationships between supervisors and practitioners" requires that both parties are willing to engage in that process.  This is not an easy skill for individuals to learn and harder for some than for others. Some of this is systematic, some of it is individual.  A system that is totalitarian in its power structure, that hinders progress and growth with disfunctional process, and relies on subjectivity rather than objectivity in information gathering will have an extremely hard time with executing change.  Individuals or groups of individuals that are defensive and untrusting, or that are over confident and full of hubris will also have personalities that will impede the process.  Again, communication and trust building require two willing participants and a process whereby both parties feel secure and safe.  "Opportunities to learn and not punish" are great in some cases, but not others.  This reminds me of the penal system's dilema of punish or rehabilitate.  Some people go through the penal system and get their act together and some do not.  Once again, some of it is system and some is individual. When we "condem the participants- by extension- the organization" we are doing an injustice.  Using one example to paint with a broad brush is lazy and inaccurate. By the same token, failing to honestly address issues for fear of bringing discredit to an individual or groups of individuals is dangerous and erodes trust.  Some individuals deserve condemnation for their actions based on their intent and willfulness. Organizations that allow members at any level to continually operate in ways that are contrary to the organization's values and responsibilities should be held accountable.

Yes, the process recommended by Professor Dekker is effective and legitimate but it requires a lot of variables to come together in the right way.  The problem in the Fire Service is that lives are constantly at stake and getting all the pieces of the puzzle together to prevent tragedies in the future may be very time consuming. Professor Dekker's process needs to begin before the tragedy because, in some cases, it is impossible to implement it in a timely way after one occurs without changing key variables (people or process).

Comment by Art "Chief Reason" Goodrich on January 20, 2011 at 10:30am

Bobby:

All excellent points; many that I can agree with.

Let me ask you something. Remember the 9/11 Commission and their report? How many recommendations made by them were adopted?

In many cases, outsiders view internal investigations as biased. Insiders view outside investigations as unreliable.

In some post incident reporting, I have seen very thorough information; as far as the information goes. How do we know that we have seen the whole picture? Remember that "you weren't there" is always going to be thrown up as a flag when deficiencies are mentioned in reports. It's a defense mechanism used world-wide and is designed to stifle questions.

If we could simply control the few who wants to take the occasion to beat up a fire department with a less than glowing report and instead use the opportunity to learn, I think more departments would be more open and less apprehensive to share the successes and their mistakes.

IMHO.

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