Culture That Kills: “We Always Did It This Way!”

By Chase Sargent

I received an e-mail from a good friend today, a captain with a major Midwest fire and rescue service. He was contacting me because he was about to enter into the chief’s promotional process and was sure something about “organizational culture” would be in it. He related the following regarding his concern for this topic on the upcoming board. I don’t have any additional information other than what I am telling you, so take this as an open-ended story with a message, not a clear statement of fact. However, you and I both know that if we have been around the fire and rescue service for a time, the content of this story is not unheard of, and you probably may even have similar stories of your own.

The Friend’s Story

It seems that Engine Company X struck Engine Company Y while running a red light at an intersection in an attempt to be first to the scene of an incident. He said the culture of the companies for years has been to be first in to an incident no matter what. It also appears that this was not the first time Engine X was involved in a motor vehicle crash on the way to an incident; in fact, it occurred multiple times in similar circumstances. (Have you heard that the definition of insanity is doing the same thing over and over and expecting different results?)

It seems that the department is upset with the chief because he demoted the captain and apparatus operator; the rank-and-file thought this was “too harsh.” However, and I don’t know the chief of the department, he offered them a second chance by allowing them to reenter the promotional process at another time-not a bad deal considering.

It seems that the chain of command (battalion chiefs and above) knew about this practice and sort of turned a blind eye. It makes me wonder why the entire chain of command was not disciplined. In the end, no one got to the incident first. Some careers were put on hold, and some feelings got hurt. The question, as silly as it may sound, is, “How the heck was this allowed to occur in a modern fire and rescue service?” It’s clear that people knew about it, and yet it was allowed to continue despite the fact that someone with any common sense could have predicted what was going to happen.

I don’t know for sure, but I refuse to believe that this department does not have standard operating procedures (SOPs) on safety guidelines for response, apparatus operation guidelines, and expectations of their officers to ensure that apparatus are operated in a safe manner at all times.

Culture Affects Safety

On June 18, 2007, nine firefighters lost their lives battling a fire in the Sofa Super Store in Charleston, South Carolina. An employee trapped in the rear of the building reported the incident to emergency dispatchers and was rescued. The rest, as they say, is history. There were multiple investigations of and in-depth reports released on this tragic event. Following are some of the report findings that show the association between the end result of fatalities and the department’s organizational culture.

  • Firefighting operations at the Sofa Super Store did not comply with Occupational Safety and Health Administration regulations, recommended safety standards, or accepted fire service practices.
  • The Charleston (SC) Fire Department (CFD) failed to adequately direct, supervise, and coordinate the firefighting operations.
  • The documented duties and responsibilities of an incident commander were not performed, and risk management guidelines were not adequately applied. The incident command system (ICS) was not implemented.
  • The culture of the CFD promoted aggressive offensive tactics that exposed firefighters to excessive and avoidable risks and failed to apply basic firefighter safety practices.
  • Insufficient training, inadequate staffing, obsolete equipment, and outdated tactics contributed to an ineffective effort to control the fire with offensive tactics during the early stages of the incident.
  • The CFD continued to apply offensive tactics after the situation had deteriorated to a point where risk management guidelines called for a defensive strategy.
  • Factors that should have caused firefighters to be removed from interior tactical (offensive) positions were not recognized.
  • There was a lack of accountability. The locations and functions of the firefighters operating inside the building were not known.
  • The CFD did not have appropriate Mayday procedures for firefighters in distress, dispatchers, or command officers on the scene.

When you look at this list, you cannot help but ask, “In today’s modern fire and rescue service, with all our advances, the ICS as the norm for operations, and safety and survival as top priorities, how can a department’s culture be a higher priority than the lives of these dedicated firefighters?”

An old friend of mine, Chief Tom Carr, formerly of Montgomery County, Maryland (now deceased), was hired to come in and get the department turned around, which he did. In the process, he upset some people who saw the old ways go. He had to make some personnel and leadership changes, and he had to shake up the place. He did it partially because it’s what he was hired to do; more importantly, he did it because he was smart and intelligent enough and had the leadership skills that allowed him to see through the trees to the forest! It makes you wonder why it took a tragedy of this magnitude to have anyone even think about getting this done. It should have been done long before any of this happened.

I could go on and on about a culture that kills in all sorts of organizations. The area of Virginia I live in is packed with military. Recently, two mobile diving and salvage unit (MDSU) divers were killed during a training dive in Maryland after a series of “cultural norms that leadership allowed to occur.” Just sit down and dig through your own department history or review most of the tragedies of the past, and you will see how to avoid them in the future.

Call it what you want-tradition, culture, ingrained ignorance, or stunning popularity-the reality is that every organization has some unspoken, yet adhered to, practices that often need to go away. Much has been written about organizational culture, but I am a simple man, and I don’t require long, flowing explanations about culture and what is good and what is bad.

Of course, if the chief of department is aware of all this “bad stuff” or lack of “good stuff” and chooses to ignore it or even condone it because he grew up in the system, shame on him. If the chain of command (division officers, battalion chiefs, captains, lieutenants, and even firefighters) choose to ignore it, embrace it, and turn a blind eye to it, then shame on them as well, because sooner or later it’s going to come back to haunt them. Someone will get hurt; someone will get killed; the department will end up in a lawsuit; and someone will say, “Gee, we have always done business that way.” You don’t want some expert testifying against you in court when you let this occur.

Leadership Rules for Evaluating Your Organization’s Culture

Following are leadership rules for evaluating the culture of your organization and answering the question, “Do I have a killing culture?”

  1. Is leadership at all levels of the organization tied in and communicating?

Does the fire chief know what is going on in the department-the trends, the “culture,” and what is accepted and not accepted? Is the chief communicating what is accepted, and is he willing to change what is not? This includes established expectations, discipline when necessary, and clearly defined norms for the organization. You cannot ignore your leadership responsibility to make sure that what you are doing makes sense, is safe, and is accepted and understood by all who work for and with you.

  1. Is there an acceptance of national standards and rules, including those to drive safely?

Does the organization have in place SOPs; an ICS policy; safety and survival guidelines; emergency response and vehicle operating guidelines; special operations guidelines; and a process to evaluate, adapt, and change quickly (temporary policies) and long term (review and update committee)? You don’t want outdated policies on the books.

  1. Does the organization know that insurance companies exist?

Structures are insured for a reason. Creating a smoking pile in a parking lot and letting your ego get damaged a bit are a heck of a lot better than a funeral or a disability. The bottom line is, does the organization clearly define when it will and will not risk personnel?

  1. Is communication up and down the chain open, productive, and nonthreatening?

Is the organization able to talk about the “tough things” without fear or reprisal? Is there a process to identify relatively quickly safety issues or “cultural issues” threatening the department and its members, and does your department review them?

  1. When you take over a leadership position, do you do a “cultural check”?

Whether you are the new chief of department, the newest lieutenant in a company, or a new battalion chief taking over the reins, do you review what is accepted and change what cannot be accepted, or do you turn a blind eye and become an enabler? Just because it has always been done that way does not mean it’s safe, justifiable, or even moral. The minute someone says to you, “We have always done that,” a red flag should go up, alarms should go off, and you should at the very least examine it. It may turn out that it’s good practice, or it may turn out that it’s not.

  1. Is what you are doing (operationally and administratively) good for the customer, good for the employee, and good for the organization, and does it promote safety and the survival of all involved?

Let’s take my friend’s dilemma with the engine companies that ran into each other. The culture of always being in first sort of got defeated, didn’t it? No one got there first. Thus, the customer was not served; the employees were hurt; and the organization now has apparatus repairs and maybe lawsuits, downtime, more exposure (other companies now have to answer the call and leave their areas vacant); and the list goes on.

  1. Does your city manager or union have a clue?

I know that’s an oxymoron! The bottom line is that you would like to think that the city managers or councils or whoever interviews, hires, and retains your chief of department has a clue about what is involved in the job and what true leadership is. However, that may not be the fact, and they may just look at a resume and how well the person speaks. Then, the manager tells the candidate the particular agenda and, if the candidate agrees, well, that person is the new chief. This is not directed at chiefs of department, but if you have been around enough, you know there is truth in this scenario.

Unions also sometimes drive things that don’t really make sense. For example, I was doing a consulting job in a major metropolitan area, developing a technical rescue team and capabilities. These capabilities were necessary because of the major construction of bridges and tunnels that required skills not previously held by the department. To make a long story short, after all the training, equipment purchases, and the team was ready to respond, the union stepped in and said, “We are not going to allow the deployment of this team or equipment unless you pay the team members an extra stipend!”

I agree that specialties need extra “pay for performance,” but you don’t risk your personnel, your customers, and your department over something like that. Those pay issues can be worked out down the road (probably they should have been worked out long before the program was developed and deployed, a recommendation that was in fact made in the project proposal). Don’t let a culture stand in the way of progress.

Cultural review and change are leadership responsibilities. It’s up to all levels of the organization to ask the hard, tough questions and get things fixed before something bad happens, not after it happens. It is hard and sometimes frustrating work.

Can you imagine being on the protective gear committee in the Fire Department of New York (FDNY) or Chicago when the departments decided to go away from three-quarter boots and move to turnout gear? Talk about some horror stories. I remember going to see Ray Downey just after the FDNY received new bunker gear and, as the alarm went off inside Rescue One, one of the members stepped forward, donning his bunker pants and saying, “Bunker pants, I love my *$#%& bunker pants!” To me it was very strange, since we had been wearing them for a decade or more! Ahh, the changes, they are a-coming!

References

http://www.nist.gov/el/fire_research/upload/Sofa-Super-Store-Study-Report-Volume I.pdf

http://www.usfa.fema.gov/library/subjectguides/subcharlestonsofa.shtm

CHASE SARGENT retired as a division chief/paramedic with the Virginia Beach (VA) Fire and Rescue Department in 2005 after 26½ years of service. He helped found and develop the Tidewater Regional Technical Rescue Team and VA-TF2 Federal Emergency Management Agency (FEMA) urban search and rescue team, which he served as a task force leader and a member of the FEMA White IST. He was the chief tactical medic for the Norfolk Federal Bureau of Investigation Special Weapons and Tactics team and has been involved in a wide range of tactical missions, executive protection, national security events, and counter-terrorism operations. He worked for Blackwater USA as a firearms instructor and Riverine cadre instructor. After retirement, he worked for the U.S. Department State Diplomatic Security Service in the Antiterrorism Assistance Program as an instructor and a special operations medic. Among his deployments were Africa, South East Asia, and the Middle East. He then spent three years in Iraq working for the U.S. government in High Threat Protection as an operator and special operations medic. He is an emergency medical physician assistant for Emergency Physicians of Tidewater.

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