BY BOBBY HALTON
There is a growing interest in near-miss reporting in our industry. This is good news for the fire service. Several programs are involved in collecting and analyzing the actions, decisions, and outcomes of these incidents. We learn valuable lessons to help avoid and prevent future events by using these data correctly. The methods and goals of groups involved in capturing these data are just as critical as the data. How we package and deliver the observations and conclusions we uncover to firefighters nationwide will be equally important. If our goals are misaligned or our processes misdirected, all the energy and time invested will do little if any good for our industry. In fact, poorly directed actions resulting from flawed data interpretations may hurt the fire service. I can proudly say that the “firefighters” in control of the processes today are passionate, focused, and striving to do the investigations the right way.
For any investigation to be useful, its goal must be to “learn from the event,” much in the way Fire Engineering has faithfully done for 129 years. Professional accident investigations recognize that the accident, injury, or mishap is a “result” of failure from within the system. The new view in human error investigations requires us to recognize these events as indications of much deeper systemic organizational issues. When firefighters’ actions are examined following an accident, we must start with the assumption that everything they were doing made sense to them at the time. This is extremely difficult for some, especially those who have never been involved in or who now are far removed from operations in the hazard zone. The firefighters involved, we must assume, were doing reasonable things given their perception of the event, the training they had, and their goals at the time.
It is not easy to study events this way. Several things bias us. First is our reaction to failure. As firefighters, we are surprised by accidents because they don’t match our expectations of our standard operational capabilities. We reject the accident because it does not match the model outcome we have in our minds for tactical operations in the hazard zone. We also have the bias of 20/20 hindsight; this makes studying firefighter accidents very difficult. We often hear ourselves saying, “What were they thinking?” In many cases, the answer is they were not thinking. They were quite naturally responding emotionally and intuitively to a very stressful and demanding event. This is not a put-down; it is a biological reality, a fundamental assumption made by researchers in critical incident decision making.
Clouded by hindsight and bias, we assume that things we know now about the event were also known to the firefighters operating at the time. We cannot understand why they did not see what we now know; we start to use what researchers call counter-factual reasoning, stating what was not done. We point out what we now know in hindsight that should have been or could have been done. The alternatives or countermeasures we learn when using this approach may be useful to others firefighters down the road who face similar situations, but they still fail to explain what really happened or why. The counterfactual options we see in hindsight were not options to the firefighters operating at the time, or they would have taken them.
It is also very difficult for us to accept that our system may be flawed or prone to failure. We invest a great deal of faith in our systems-command, air management, accountability systems, and so on. We do not want to believe our systems are flawed because it means we and our fellow firefighters are at risk for the same accident. Worse yet, this accident may just be the dress rehearsal for a bigger and more catastrophic event. This does not mean people do not mess up. We do. It means in the greater sense firefighters are more often responsible for making systems function safely and properly than systems are responsible for making firefighters safer and responsible.
Often we use the traditional “Bad Apple” theory when approaching an accident: We assume someone simply made mistakes, someone violated procedures, or someone failed to use good judgment-and that someone is to blame. Simply highlighting someone’s mistakes explains nothing. Simply saying what the firefighters did does not help us to understand the whys of the decision. The “Bad Apple” theory gives us a scapegoat; it is the easiest conclusion to arrive at in an accident review, and we throw the label “human error” on the event, identifying with our hindsight what the firefighters should have seen or should have done. This also makes us feel safe because then we can purge the bad apple, and we have no more worries. Using bad apples, we also now have someone to hold accountable to punish or to sue.
Punishing someone in the fire service who was operating in the hazard zone accomplishes nothing and may encourage others to avoid reporting incidents for fear or punishment. Rather, it must be the goal to try to get inside the minds of the firefighters who were there and understand why what they were doing made sense to them at the time.
I know the people behind the scenes at firefighternearmiss.com and firefighterclosecalls.com, and they are going the extra mile to look beyond the obvious. It underlies the meaning of the term “brotherhood”; we must believe that every decision, regardless of its appearance in hindsight, was made with the best of intentions by the firefighters doing the work. When our near-miss reporting and close calls recommendations consistently reflect this mindset, the fire service will be a safer, more educated, and more effective place to do our work. Report your closes calls and near misses. It is another way firefighters save lives every day. And remember, we can fix the systems only when we know the shortcomings.
