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Operational Risk Management: How To Make Good, Defendable Decisions On The Fly

Standard operating procedures (SOPs), rules and regulations, departmental orders, and other policies and training procedures serve as the basis for operational risk management and the decision-making process that occurs within fire departments. These guidelines are established for events which can be identified in advance, for example, having procedures in place that address when an employee is late for work, identify company response assignments, or to identify the steps to take when treating a heart attack victim. Having operational procedures in place simplifies the decision making process, justifies actions taken, weighs the risk and benefits, and creates safe, effective, and efficient operations. But how do we make good defendable decisions on the fly when no established procedure or experiential base exists for a given call type?


To be effective, among other things, company officers must be decisive. Having established guidelines in place makes decision making easier, because we can call on familiar processes to make decisions about high frequency events, things we respond to and deal with regularly. On the other hand, we usually do not have procedures in place to deal with low frequency events, where making decisions may become more difficult due to limited experience.


Decision Making


As Risk Manager Gordon Graham puts it, “Imagine your brain is a computer hard drive. Everything you do and experience at work and in life is loaded onto your hard drive. When you get involved in any task or incident, your brain quickly scans your hard drive looking for a close match. When it finds a match or key elements in a given situation, it offers recommendations on how to deal with a particular circumstance. This process is called Recognition Primed Decision-Making (RPDM).” Dr. Gary Klein is the creator of RPDM. Many of us utilize this decision making process naturally. We just know what to do as a result of our experiences. RPDM allows individuals with experience to make reasonably correct decisions. RPDM involves four steps to decision making:


  1. Prototype Match - Have we seen this before?
  2. Expectations - Established by your prototype match, what did we do before and what were the results?
  3. Evaluation - Is course of action plausible?  RPDM looks for a solution, not necessarily the best solution.
  4. Implementation - If course of action has a reasonable chance for success, it is implemented. If course of action has no reasonable chance for success, modify the course of action or pick another option.


RPDM works well for recognized situations, but should not be used to make all decisions. In fact, because this model is easy to use and works well, it is often used as a default mechanism for decision-making.


Classic Decision Making (CDM) is another method used for making decisions. The CDM model has been taught for many years and is one of the best ways to make a decision if you have time and information. CDM also involves four steps to decision making:


  1. Aim – What do we want to accomplish?
  2. Factors – Anything that affects the decision.
  3. Courses – Establish 3 or more ways to accomplish the AIM.
  4. Plan – Choose the best course of action and establish a plan to implement the course of action.

While the CDM works well, it relies on time and information, so it is not as effective as RPDM in emergency situations where a decision needs to be made quickly and there is no discretionary time available for in-depth analysis.

Risk Management Plan

During mitigation efforts, decisions must often be made with little time and information, especially when lives are at stake. The risk and benefits must be continually weighed. The fire service recognizes a simple risk management plan, introduced by the late Alan V. Brunacini, retired Chief of Department for Phoenix Fire Department, that aids in the decision making process.


  • We will risk our lives a lot, in a calculated manner, to protect SAVABLE lives.
  • We will risk our lives a little, in a calculated manner, to protect SAVABLE property.
  • We will NOT risk our lives at all for lives or property already lost.


Most of the time this plan is recognized as it relates to fire emergencies, but I believe it is equally effective in dealing with all emergencies.




Having discussed methods available for making decisions, let’s have a look at the Risk/Frequency Chart to identify where we are most vulnerable to risk. The chart identifies four specific areas of risk and frequency. Low Risk/Low Frequency events are not a big deal to us, because the consequences are not that severe. High Frequency events generally do not cause problems except when complacency, fatigue, distractions, hubris (excessive pride and self-confidence), and risk homeostasis (we are invincible) are involved. The area of the chart that leaves us most vulnerable is the top left box, High Risk/Low Frequency. These are situations that have life threatening consequences, happen so infrequently we lack experience in dealing with them, and do not have information on our human hard drives to help guide our decisions.

Notice the dividing line in the High Risk/Low Frequency category. This line indicates a distinction between High Risk/Low Frequency events with Discretionary Time (DT) and those with Non-Discretionary Time (NDT).


DT affords an opportunity to analyze a given situation and to make decisions with time on our side. Take for instance a hazardous materials or bomb incident. With the exception of life safety, there is usually no reason to rush these incidents. Many of the incidents we respond to can be considered DT type incidents. We create many consequences for ourselves when we fail to use time when it is available.


NDT incidents increase our vulnerability by not affording us more time to think things through. These are situations where we must act immediately; take for instance, a structure fire where savable victims are trapped.




Active shooter incidents, unfortunately, are becoming commonplace, but remain high risk/low frequency events for many fire departments across the nation. The danger lies in the fact that many departments have not run this type of incident yet, so they do not have an established experiential knowledgebase that helps them recognize what they should know and do, unless they are proactively training for this type of event. For many of us, the active shooter response has not yet become second nature, which I suppose is a blessing and a curse.


Hypothetically speaking, you are called out to a school shooting. Local police are responding and attempting to secure the scene, and chances are Fire/EMS units are entering the area at the same time. The number of shooters, types of weapons, and the location within the school are unknown. Single and rapid-fire gunshots can be heard from time-to-time. You witness students and teachers exiting one wing of the building; some appear to be injured and bloody. Some of the evacuees tell you more of their friends and teachers have been shot, but are alive in the hall about 20’ from the exit door. They state the shooter came down the hall, fired multiple shots then left, but they are not sure where the gunman went next. What are your considerations and decisions? What actions will you take as a result of your considerations? How much time do you have to decide on your actions, and do you have sufficient resources to support you?   What are the unknowns (explosives, multiple actors)? Have you trained for this? Have you seen this event before? Do you have an SOP in place to provide initial guidance? These are just some points to ponder and may be a starting point to begin your discussions, planning and preparation for an active shooter event.


Agencies like the Arlington County, Virginia Fire and Police Departments, as well as the Fire Departments of Northern Virginia have been at the forefront of creating nationally recognized standards to respond to active shooter events with Tactical Emergency Casualty Care (TECC) that is supported with ballistic personal protective equipment and rapid treatment medical supplies or “Go-Bags” (prepackaged medical supplies specifically geared toward bleeding control). If we stop the bleeding, we stop the dying. Ongoing and joint exercises hone personnel skills and decision making in order to make members familiar and effective in responding to particular high risk/low frequency events. The addition of a unified command between Fire/EMS and Law Enforcement helps to coordinate efforts and maintains situational awareness and expertise. Joint and agency specific training is frequent and ongoing, as it should be.

Final Thoughts


I believe the Risk Management Plan can be effectively applied to all emergencies to aid in making good defendable decisions, but especially in critical situations where no clear or defined SOP exists. Further, proactive training for high risk/low frequency events takes a relative unknown and makes it more familiar to personnel by providing a foundation to begin from. The training offers a practical experience to help anticipate how the real incident may play out. It affords opportunities to identify lessons learned and reinforced, and to refine operational considerations, tasks, and decision making. Situational awareness is heightened and therefore more effective. The establishment of SOPs further aids in the decision making process for predictable and preventable situations.


By preparing for high risk/low frequency non-discretionary time events, we can become more effective and efficient at protecting ourselves and those we serve through good defendable decision making.




Gordon Graham, Organizational and Operational Risk Management


Dr. Gary Klein, “Sources of Power: How People Make Decisions”


NICK J. SALAMEH is a 36 year veteran of the fire service. He was a Fire/Emergency Medical Services Captain II and previous Training Program Manager for the Arlington County (VA) Fire Department, with which he served 31 years. He is a former Chair of the Northern Virginia Fire Departments Training Committee. Nick is a contributor to Fire Engineering Magazine, and Stop Believing Start Knowing (SBSK),

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