By Andrew Beck
Too often in the fire service, when we look at a serious accident report, or NIOSH LODD report, we say to ourselves, “They did everything they could, and it was a completely unpredictable event.” Thoughts like this help us feel more comfortable working in the dangerous environment we work in, and let us feel more confident about our level of control over these hazards. But is that the best way to look at an event?
It’s easy when reading a report about a fireground emergency to assume that chaos and unpredictability is just a way of life for us. We sometimes even write the event off as something that “just happens.” We think to ourselves, “no one could have known that was going to happen, it was completely unpredictable.”
While this can sometimes be true, it can also lead us into a cognitive trap. Many times, when we peel the layers of an accident back, we find it’s not as unpredictable as we initially thought. By doing this, we can start to become better at determining root causes and making real changes that will make our job safer for everyone.
Understand underlying causes of firefighter LODDs
When an accident happens, there are a couple of ways to investigate it. Broadly, we can focus on either the who or the what. One will result in potential punitive changes and no real improvement. The other takes more work but will be an investment in your organization that will pay dividends later.
Traditionally, when an accident happened, a department looked at it from the standpoint of individual actions compared to SOPs or SOGs. The goal is identifying rules violations or if additional policies are needed. There are situations when this approach is necessary, such as the case of willful violation of policies.
The hazard comes when we use this system to analyze actions taken in the chaos of an incident. In this case, people are operating with few options, and in a stressful situation. This predisposes them to make mistakes. This type of investigation rarely looks at the conditions that got them into those positions, but analyzes merely the last couple mistakes. This means that while department members will know to pay attention to those last couple items, they will still be operating in a manner that can lead them to having another failure.
An alternative method is to try to analyze the underlying factors. Start at the incident, and work backward through the event, creating what is called a “chain of errors.” Each time you come upon a mistake or error, ask, “why did this happen?” and look for the next link. This will allow you to start to determine some of the latent factors that are present in your organization. These latent errors can be the real cases of people being in the situations that resulted in them making the final mistakes in that environment that we wrote off as being so unpredictable.
Use vicarious learning to prevent firefighter LODDs
It’s interesting that you can generally grab a group of firefighters and ask them what the leading causes of LODDs in the U.S. are (cardiac issues and driving accidents), as well as some common factors that are present in severe accidents and LODD reports (lack of communication, loss of situational awareness and complacency).
These same people sometimes also look at an incident report and shrug the event off as entirely unpredictable. There is a cognitive dissonance at work here. If we can identify these common causes and leading factors that are present when our brother and sister firefighters are hurt and killed, then really how unpredictable are they?
No one would argue that once a situation degrades into a life or death survival situation, that it’s difficult to always make the right decisions, and mistakes will be made. It is also likely true that some very predictable factors lead to the person ending up in that survival situation. The question is, how do we become more aware of these factors ahead of time?
One method that the fire service has used for many generations is telling stories. Around the kitchen table, on tailboards and in truck bays, most of us have heard a senior person in our organization share a story about a time that something happened. These stories can make us laugh or feel the fear that the storyteller felt in that moment. It’s also likely that we remember these stories and can recall them later. This oral tradition has allowed us to pass knowledge from one generation of firefighters to the next. Stories can also pass on negative and dangerous practices, so you have to be careful what stories you listen too.
The next time you hear a story about an accident, listen and put yourself in the storyteller’s shoes, and try to determine why the decisions were made the way they were. Would that still happen today? What did the person have for options when they made the decision? What did they see? This can help you feel the emotion that they felt and integrate the lessons almost as if you were present at the time. Called vicarious learning; it can be compelling.
Teach situational awareness
The problem is, you and the other members of your organization have only experienced what your organization has experienced. Lack of these experiences leaves you blind to potential flaws that have not come to the surface yet. How do you hear new stories to help you realize when your actions might be on the predictable path to an unpredictable situation?
The Firefighter Near Miss reporting system of the International Association of Fire Chiefs was founded in 2005 to provide a national system to collect and disseminate these near-miss stories. The system contains about 8,000 reports of times when things either went wrong or were prevented from being worse by a best practice. They were entered by responders across the U.S. and Canada who wanted to share their stories and allow fellow responders to learn their lessons. You can search the reports by topic, and use the reports to illustrate points during training or for crew briefings.
You can read these stories, learn from them, share them and then use them as a tool to analyze the chain of errors that might be present in your agency. Then, you can get to work eliminating these items. This will lessen your chances of ending up in a predictably unpredictable situation, and make your environment safer and more resilient.
About the author
Andrew Beck has been a member of the program staff for the IAFC’s National Near Miss Program since 2015 as an instructor, reviewer and subject matter expert. Andrew started his fire service career in 2002 with the U.S. Fish and Wildlife Service, working in wildland fire operations. He then worked in wildland fire for the U.S. Forest Service from 2003-2006, when he transitioned to structural fire with the Mandan City Fire Department in Mandan, North Dakota. He is currently the training officer managing department training programs and live burn operations. Andrew teaches thermal imaging at various regional fire schools and is a live fire instructor for the state firefighter’s association. Andrew lives in Mandan with his wife Ashleigh, and their four kids.
