BY JERRY HOLT
We’ve got to change the way we do things. It’s a simple statement, but a challenging task. We have heard the cry for cultural change in the fire service for years, but sometimes it feels as if things never change. We know that some of the things firefighters do increase the likelihood of death or injury, but we continue to act in a highly predictable manner and are shocked at the consequences.
Many educational initiatives designed to address the culture of the fire service are underway. Many experts and classes tout the need to change the fire service’s culture to significantly reduce death and injury rates; most of the classes include a component that addresses culture. The International Association of Fire Fighters (IAFF) Frontline Safety course is one of the many resources available to improve firefighter health and safety. It does an excellent job of addressing some of the key issues that are often at the heart of firefighter deaths and injuries, exploring the fire service’s safety culture and how our firefighter values might not always match our actions. As a student in the IAFF’s Frontline Safety two-day course, I was happy to see more than a few “ah ha” moments among attendees.
(1) Firefighter safety must always take priority over property, even at bread-and-butter operations. The risk must always be worth the gain. At this incident, the fire began in a vehicle in the garage and had extended to the rooms above prior to the fire department’s arrival. The incident commander (IC) met the occupant and verified he was the sole occupant. Since the fire occurred during the day, the combination department’s staffing was limited. The IC requested mutual aid and used defensive tactics to save savable property without endangering firefighters and quickly controlled the fire. (Photo by Steve Bunce.)
The IAFF class covers many aspects of safety. Participants must complete a personal safety survey, explore safety truths and myths, and perform exercises in identifying unsafe acts. These activities encourage students to complete an introspective personal inventory of how their actions reflect their commitment to safety, which is a valuable tool for improving firefighter safety. After all, repeating past mistakes is what continues to plague our efforts to reduce line-of-duty deaths and injuries. We are repeating some of the highly predictable mistakes, many of which arise from our tradition-based culture.
FIRE SERVICE CULTURE
What is culture really all about? Organizational culture is “a system of shared meaning held by members that distinguishes the organization from other organizations.”1 Culture makes our organizations what they are and varies greatly from one fire department to the next. It is based on the positive and negative values (firmly held beliefs that drive members’ actions) of a given group’s members.
One positive value that distinguishes the fire department from other organizations is that firefighters respond to calls for help and generally our customers are happy to see us. A negative value may be how we respond to those calls, sometimes without regard for our own safety. Interestingly enough, members from within our ranks have identified this item, not our customers. Some customers are unlikely to be interested in a risk assessment when their property is on fire. Regardless of the risk to firefighters, our customers want the fire extinguished, and they want you to arrive quickly to do it.
Fire service culture and values vary widely from state to state, region to region, and even from department to department, which is one reason making meaningful change in our fire service culture is so difficult. Some departments may greatly value emergency medical services; others may see it as an unnecessary function. That’s culture. Making a cultural change within your department would be challenging; making one throughout the American fire service would be monumental. Although many of us believe that cultural change is necessary to increase firefighter safety nationwide, many of our actions do not match our stated values regarding the very items that we have identified as needing to be changed.
The IAFF Front Line Safety course emphasizes how our actions do not always reflect our values. Divided into four groups, participants must identify the personal and work items that their groups value. Firefighters develop their individual list and then the group makes a list of shared values. Not surprisingly, the list of top values for each group was similar. All groups listed “family” at the top of their lists.
The conclusion: The values of the groups likely represent the values of firefighters everywhere. Given the strong family culture of the fire service, I was not surprised to see that as one of our motivations. However, looking back at the personal safety survey, we saw how some firefighter actions do not reflect what we said we valued the most.
If family is so important, why don’t we do a better job of protecting ourselves for the sake of our families, who we say we value so much? If we really care about family above all else, why don’t our actions reflect that? Do firefighters who drive recklessly or refuse to wear seat belts really demonstrate that family comes first? How about committing resources without conducting a risk-benefit analysis? That certainly doesn’t put the fire department “family” at the forefront of our actions, nor does it contemplate the impact on a family left behind when a firefighter is lost while fighting a fire in vacant structure.
So why do we take actions that are inconsistent with our stated values? Because we have done it that way many times without a bad outcome. This class introduces students to “the normalization of deviance,” how we accept things we should not accept even when there may be deadly consequences.2 Chances are that if you have been on the job for any length of time, you have engaged in some form of normalization of deviance. Have you ever taken a safety shortcut and gotten away with it? I will bet that most of you have. When you do that and there is no negative outcome, you are likely to do it again. Do it enough, and the shortcut becomes the new norm. Below is a classic example.
The New Recruit.
A new recruit has just completed initial training and has been assigned to a shift. Full of knowledge and well trained on the proper methods of performing the tasks the job requires, the recruit is a walking check-off sheet on the proper performance methods for recruit school tasks. He’s assigned to B Shift (we all know how they are), and the B-Shifters are quick to impart their “real-world” knowledge to the new guy. In the first month, the new recruit learns that some of what was taught in recruit school is simply not the way “we” do it. Shortcuts that can compromise safety quickly replace some of the good habits he learned in recruit school. After the recruit applies those shortcuts a few times and nothing goes wrong, the shortcut becomes the normal operating procedure. That same recruit can’t wait for the next new person to come along so that he can show the new guy how things are done on their shift.
The Challenger Disaster.
In the IAFF class, the classic example of the normalization of deviance had the ultimate consequence—the loss of life. The class included video featuring space shuttle astronaut Colonel Mike Mullane discussing how the normalization of deviance in the Challenger disaster affected the shuttle program.
The Challenger disaster occurred in January 1986. Seventy-three seconds after liftoff, the Challenger disintegrated when an O-ring failure allowed pressurized gases of more than 5,000°F from within the solid rocket booster (SRB) to escape. Those gases impinged on the mounting hardware and the external fuel tank, causing the hardware to fail and allowing the top of the SRB to be pushed into the external fuel tank, causing it to fail. The aerodynamic forces caused the Challenger to break up, and all seven crew members perished in the accident.
Just another disaster? Not really. The subsequent investigation revealed that the Challenger disaster was a highly predictable event and there were many warnings. One of the “fly or no fly” issues for the space shuttle program was O-ring damage. If any evidence of O-ring damage was found, the next scheduled flight was to be grounded. Such problems were identified as early as 1977, and it was known that any failure of the O-rings could lead to catastrophic failure and death of the crew.
After the O-ring flaws were identified, adjustments were made within the program. Instead of grounding the flight as previously planned, NASA and Morton Thiokol (the company that built the shuttle) worked through a series of “tweaks” to the production process. Many Morton Thiokol engineers believed that the O-ring problem had not been adequately addressed and feared there would be a failure. However, several shuttle missions were launched using the same O-ring system, and there was no further evidence of a continued problem.
Launching the shuttle during cold weather was one of the especially dangerous scenarios. On the morning the Challenger was launched, the weather was just the kind of cold that engineers feared would cause a problem with the O-ring. Morton Thiokol engineers once again pleaded their case and urged that the mission be delayed. NASA officials, citing the lack of data indicating further problems with the O-rings, decided to go ahead with the launch. During the launch, high-speed footage of the launch revealed a leak had occurred. As the shuttle ascended, a plume of superheated gases escaped and caused the eventual breakup of the Challenger.
The postincident investigation results showed how normalization of deviance contributed greatly to the disaster. Engineers and NASA officials were aware of the dangers with the O-ring, but since they had several successful missions, they accepted that risk even when they knew of the potential dire consequences of a failure.
NO SHORTCUTS TO SAFETY
Can the same thing be said of the fire service? How about your department? Although we are educated and well aware of the potential consequences of failure in our system, since we got away with it last time and many times before that, it has become the normal mode of operation. In fact, you can just change the titles of the players to see what I mean. Substitute Morton Thiolok engineers with the fire department chief who is arguing for increased staffing. Substitute NASA officials for the city managers or mayors and councils asking for the data that show where someone in your department got hurt because there wasn’t enough staffing. You get the picture.
But city managers, mayors, councils, and fire chiefs are not the only ones to blame; much of the responsibility rests on our shoulders. We have normalized deviance at the street level; each time we take a shortcut, we are that much closer to another disaster. Maybe it is minor and affects only an individual’s health and safety, or maybe it is bigger and affects several companies operating at the scene of an incident. Have you ever not used eye protection when you should have? How about taking off your self-contained breathing apparatus mask during overhaul before you really should have? These little things potentially have very big consequences.
Often, we are merely along for the ride—passengers who don’t have any options. But we really do have a choice: We can “go along for the ride,” or we can speak up when we need to and operate as safely as possibly with the resources we have. It goes back to that culture thing: We often try to operate as if we had all of the resources we need when we really don’t. Have you ever seen crews make an aggressive interior attack without following the “two-in/two-out” rule? These are not “bad” firefighters. The culture that says we must do something even if it means great personal risk drives their actions, even when there is nothing to gain.
How about making an attack on a building that was lost before you arrived? I’ve heard the reasons: “If we don’t, we will lose the structure!” So what? If you lose the structure because you don’t have enough staff to safely extinguish the fire, so be it. That gives the chief the data he needs to demonstrate the need for more personnel before the city administration.
Of course, I understand that not all situations are that simple. Property is property, and if it is lost because we do not have adequate staff to save it, well, it is just property. It is complicated when there is a life to be saved. That’s when it gets dicey. We all should be prepared to risk our lives to save lives. According to the basic premise, we will risk a lot (our lives) to save a lot (savable lives), we will take calculated risk following our standard operating guidelines to save savable property, and we will not risk our lives to attempt to save lives or property that is already lost. We will only risk our lives to save lives, and that’s the way it is.
Other times demand that we speak up and not merely become passengers. Crew resource management (CRM) is a great tool to help in this area. CRM obligates everyone to be part of the team and ensure that we get it right, 100 percent of the time. At least one text suggests that eight out of 10 firefighters would not tell a supervisor of an actual or perceived danger even when they thought it might result in serious injury to them or their coworkers.3
Unfortunately, case studies back that up. We’ve all seen examples of firefighters who merely went along for the ride, or perhaps we went along for the ride ourselves. Have you ever attempted a fireground assignment about which you had serious safety concerns (you probably have if you’ve been around long enough), but you went ahead and attempted the assignment without questioning?
Consider the following scenario: Firefighters are sent to side C to make an entry. When they get there, they find heavy fire and smoke conditions, but they attempt entry anyway, only to be driven back. Their turnout gear is damaged by the extreme conditions. Perhaps they should have relayed the conditions to Command before attempting to make entry. Perhaps Command would have changed or adjusted the assignment based on the crew’s findings. But Command did not have that option; Command did not find out about the conditions the crew encountered on entry until later. The crew acknowledged that it was “too hot” to make entry, but they did it anyway because that was their assignment. They were merely along for the ride and are lucky that only their turnout gear was damaged. They should have spoken up.
Evidence suggests that there is some level of compliance in our attempt to make cultural safety changes. Compliance is defined as change that occurs when a subject publicly accepts an influencer’s position but privately maintains his original beliefs.4 Although an individual follows the policy, that person has no “buy in”; the member is “just doing what I am told.” Many fire service leaders have led the charge to change how we approach safety. Only after great effort have we made some positive changes in our culture. But to get to the level where we have a significant positive impact on the health and safety of our firefighters, we need conversion. We need to get to the point that those who initially held different opinions on the safety efforts change their way of thinking and come to share the belief that those safety efforts, the new safety culture, are correct and worthwhile. When conversion occurs, firefighters are part of the cultural change because they believe that a “new” culture offers something positive.•••
If we are going to change the culture of our profession, we have to change ourselves. This monumental task will take hard work and dedication. We must identify our organization’s values and closely match our actions to them. It is not about the chief’s latest attempt to make us a “value-driven” organization; it is about making sure that everyone goes home. We must guard against the normalization of deviance. We cannot take shortcuts and assume they will not affect our health and safety. It is up to all of us to make a difference. That difference starts with you.
1. Judge, T. A., and S.F. Robbins. (2007). Organizational Behavior(12th ed.). Upper Saddle River, NJ: Pearson Education, Inc.
2. International Association of Fire Fighters (2009) Frontline Safety Student Manual. Washington, DC: IAFF.
3. Lubnau II, T., R. Okray. (2004). Crew Resource Management for the Fire Service. Tulsa, OK: PennWell.
4. Forsyth, D. R. (2006). Group Dynamics (fourth ed.). Belmont, CA: Thomas Wadsworth.
● JERRY HOLT,CFO, is chief of the Urbandale (IA) Fire Department, a nationally registered paramedic, and a graduate of the National Fire Academy’s Executive Fire Officer Program. He has associate degrees in fire science and EMS and a master’s degree in leadership.