WHEN SOMETHING GOES wrong, we immediately start looking for someone to blame. Blaming is a normal gut reaction, and we all do it. Other than making ourselves feel better, what are we really accomplishing when we affix blame? What is it that drives us to want to quickly find a scapegoat? Today the Internet provides the opportunity to affix blame instantaneously and to a worldwide audience. However, if our desire is to make positive improvements, we have to ask what value comes from blaming.
We sometimes feel differently after we have asked a couple of important questions first: Were the firefighters involved really in complete control, and are they truly to blame? Did they really have the authority to direct the dozens of different issues that combined to create this disaster? I am not saying that blatantly negligent or willfully dangerous acts by individuals who knew better should not be punished. Those are obviously inexcusable. I am talking about fireground incidents during normal work that are rarely that simple or clear-cut.
I also am not absolving leaders who are guilty of repeatedly failing to provide for and protect their troops. Leaders-fire chiefs, in particular-are responsible for the decisions they make with regard to equipment, procedures, staffing, and training. Leaders should always step forward to accept the mantle of responsibility; the buck stops with the chief. I say this, understanding that many fire-related tragedies are the result of a combination of deeply systemic, interconnected decisions that usually exceed one fire chief’s tenure.
Chiefs can and do fall undeservedly-it comes with the territory. But what should never happen is the vilification of the firefighters who were engaged in normal work. I acknowledge that we firefighters have important responsibilities that directly affect our citizens and each other. Nevertheless, before we assign blame, we should ask ourselves, have we completely captured the true cause or causes of the event? Good investigators tell us that when they investigate all the linkages surrounding an incident that involves a firefighter death, the causes and effects are often very hard to separate.
We want to quickly blame people when bad things happen, primarily to reassure ourselves that we are still in control-that had it not been for the perceived negligence of “The Bad Apple” (bad officers, reckless firefighters), the tragedy would not have happened. We reason that if they had followed all the rules and did everything right, this would never have happened. We fail to understand that in our very complicated systems, and even more complex incidents, our past successes do not ensure future success. Even doing everything right does not guarantee our safety. When we hold someone “accountable” in our effort to find closure, we stop the opportunity for learning. All we are doing is reassuring ourselves that the system is now safe with these bad apples out of the barrel.
The theory at work here is that by holding someone accountable, we have identified that they are or were bad apples. We create villains out of them by convincing others and ourselves that they were lousy officers or lazy and stupid chiefs. We want to reassure ourselves that we are not at risk of meeting the same fate. We believe we are making the fire service safer when we get rid of those miscreants, those deviants. We make them bad to separate them from us and our system. If we get rid of a few officers in a division or district, then the division or district is now safe again.
We see it all the time, and recently it has been suggested that legal action should be used to further punish these tragically flawed individuals. The problem with this approach is that it produces little improvement to our work because we stop the accused from telling their side of the story. We know we learn a lot from hearing stories of others, especially after the participants have engaged in retrospective reflection. We can learn what prevented them from seeing the things that we saw so clearly from the cheap seats, as we “Monday morning quarterbacked” the incident. We are mortified they missed the things that we see so clearly in hindsight, but we fail to figure out why.
Real learning involves looking at the decisions that, in hindsight, proved to be flawed by examining them with the same set of eyes as the participants. We learn when we understand and appreciate the time pressures they faced and what information and resources, or lack thereof, they had. When we fully take into account their experience, training, and personal history, when we try to become them, then we learn.
This gives us a true foundation from which we can begin to create models of that experience to help us to avoid the same crash. With a set of lessons learned that are carefully implemented and continuously reviewed, we are practicing true continuous improvement. Bad bosses know that the early execution of subordinate villains is the best protection for those at the top of the food chain. The purging and subsequent complete humiliation and discrediting of the bad apples stop us from looking any further for answers-certainly not at ourselves or our sacred systems. It is not an easy thing to find real answers when horrible things happen on the fireground, especially when we can simply throw out a few bad apples. I wish it were.
