BY BOBBY HALTON
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 directly connected to learning—especially learning from incidents that did not go well or resulted in tragedy. This learning is deeply connected to our number-one principle: 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 the exemplary and well-distinguished Captain Charles Butler McVay III, and be responsible for his suicide 23 years later.
On July 30, 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. When they were rescued five days later, only 317 survived exposure and relentless shark attacks. 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 its history, the Navy quickly looked for someone to blame. Many years after McVay’s conviction, significant evidence surfaced that proved the captain’s innocence. First, the Navy never told the captain that there were submarines in the area. Second, the Navy refused the captain’s request for an escort. Third, 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 we have created are safe. For years, many people have said that systems keep people safe. Recent works by brilliant people such as Sidney Dekker, Gary Klein, and others have proven that systems do not keep us safe; rather, 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 as intricate as 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 on their experience, knowledge, and best understanding of the situation. What they chose represented the very best decisions they could have made to affect the situation in a positive and safe manner.
Unfortunately, we are seeing this growing trend toward 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 event outcomes were rooted in systemic issues and complex interrelated activities that no one individual was solely responsible for or in fact was even able to affect.
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 nonpunitive 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. Storytelling 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 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.
