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.