Tailboard Talk: HROs Use Human Factors to Improve Learning Within the Organization

By Dane Carley and Craig Nelson

An awareness of human factors began developing around the time of the Industrial Revolution. As humans began interacting more with machines, it became apparent that machine design must account for human interaction. Fast-forwarding to the development of aviation machines, this awareness led to a strong focus on human factors in the design of airplane cockpits. Aviation engineers discovered that if important switches were in the right place, they would be easier to find or less likely to be accidentally bumped (important when you’re racing across the sky at 500 miles per hour!). Human-factors science has continued growing into other areas of manufacturing, processing, engineering, design, military, and government industries in an effort to boost productivity and increase safety.

Machines are considerably safer and more reliable, yet accidents still occur in large part because humans interact with the machines, making the human factor the highest cause of accidents today. Thus, human factors in root-cause analysis of accidents are key components of two of the five higher reliability organizing principles discussed in our first article. Higher reliability organizations (HROs) strive to develop a learning culture that considers human factors, which evolves from the principles of a preoccupation with failure and sensitivity to operations.
Human beings, believe it or not, have limits. We see this often and up close in the fire service when someone tries to defy the laws of gravity by attempting stunts that end unsuccessfully. Human limits are not only physical; they are also mental. As gifted as firefighters are, we sometimes encounter situations that may overload our mental capabilities, leading to errors. Human-factors research studies how humans think, act, and react to their environment in an effort to find methods that make our jobs, equipment, and actions safer.
In our case, the discussion of human factors relates to firefighters by studying our interaction within the various dynamic fire service environments. For example, we think of driving a fire engine to an emergency as a relatively simple task because we do it often. But behaviorists studying human factors would consider the multiple tasks occurring while driving a large vehicle at high speeds: operating lights, sirens, and air horns; maneuvering through traffic; planning routes; recalling building access; and spotting the vehicle. Our senses work together to make it seem as if we are multitasking to accomplish all of these things at once; in reality, our brain is switching between the senses up to 60 times per second to give us that illusion.1 Behaviorists recognize that our brain can perform only one task at a time and use this as one perspective while studying human factors. 

As with other industries’ machines, our apparatus are safer today than ever before. Yet, response fatalities have remained relatively stagnant over the past 20 years because of the many human factors involved with driving, as is the case with many aspects of fire service work. We seem to create a lot of hype about making the work safer, but are we focusing our efforts in the right places? There may be more effective methods to improve safety and reduce stagnancy.


Figure 1: This figure illustrates the number of times a factor contributed to a near miss incident (National Fire Fighter Near Miss Reporting System) 

Looking at firefighter near-miss statistics shows that human factors contribute to a strong majority of incidents. Based on the categories presented in the firefighter near-miss statistics in Figure 1, we believe all of the categories except for “equipment” and “other” can be directly related to human factors. Have you ever stopped to consider how these factors are likely to affect you, your crew, your equipment, and your daily operations? These 16 root causes lead to most of the incidents in our industry, yet we focus on a multitude of symptoms of these root causes. Why do we still see the fire service behavior of not wearing a seat belt even though we have been treating the symptom by preaching about wearing a seat belt for years? Until those of us who work in the fire service begin to focus on the human factor-related causes, we will continue opening ourselves up to becoming a statistic!


Figure 2: Proportion of aviation incidents caused by machines compared to humans (Nagel, 1988).
A look at the aviation graph with many years of statistical data in Figure 2 reveals that machine causes of accidents have significantly decreased while the proportion of human causes have significantly increased. Likewise, Figure 3 illustrates the proportion of fire-service incidents caused by machines as compared to humans; however, the fire service is just beginning to collect similar data. Given the amount of information we now have available, we are generally paying very little attention to human factors, but our hats are off to the departments that are. Now when we honestly look at the root causes and the FACT that they are largely human-factor related, we can begin to embrace these methods to improve safety and effectiveness.

Figure 3: Proportion of fire service incidents caused by humans compared to machines for three years.

The fire service lists reasons for not accepting this approach. Or, are they just excuses? Is it possible the real reasons stem from a lack of awareness, being unaware of the benefits, feeling threatened by it, being afraid that it will expose a weakness, or not knowing how to implement it? To transition to a HRO, the fire service needs to develop a learning culture starting with seeking answers to these questions. 

A HRO operates according to the five principles discussed in our first article. However, a persistent culture of learning is fundamental to the success of the five HRO principles. The principles cannot exist without a constant desire to learn and apply the gained knowledge to operations. Therefore, HROs perform root-cause analyses of incidents, which typically find that humans’ reactions to the environment in which they were operating contributed to the incident. However, the focus is not on who made the errors but on why the person made the decisions leading to the errors. Root-cause analysis focusing on human factors often finds that organizational culture, organizational stories, and organizational structure lead to the pattern of decision making contributing to the near miss rather than an error made by a single individual,3 Therefore, HROs adjust their operating environment, which includes everything from engineering controls to organizational behavior, to prevent future incidents from the same root cause. As we begin to learn from human factors, we must track our near-miss incidents to build a solid base of information for trending root causes that can then be applied in a positive learning environment. In the next article, we will look at near-miss reporting, tracking incidents, and trending data to identify root causes. 

Case Study

The following case study, taken from the Firefighter Near-Miss Reporting Web site, provides a good example of human factors contributing to a near miss. Go to the Firefighter Near Miss Reporting Web site and search for report 10-0001136. 

Event description (as described by person reporting incident).

Our engine was dispatched to a reported structure fire at a local apartment complex, with the callers reporting visible smoke and fire. On arrival, we found a three-story apartment building in the complex showing heavy fire from the A/B corner, extending from the first division up and showing through the roof. My initial assignment was to throw a 24-foot extension ladder, which was quickly changed to operating the engine’s deluge gun to achieve a quick knockdown and allow us to enter the affected apartments. 

I climbed up on the truck and disconnected the deluge gun from its base, to place an extension (pipe) on it to allow for greater reach and penetration. Placing the pipe was a standard practice among our shift’s crew, and when it was done in the past, the engineer would ask the firefighter if he was ready for water prior to charging the deluge gun. On that shift, the engineer was acting captain, and a firefighter from another station was detailed to drive. Shortly after I had the deluge gun disconnected from its base, a jet of water came up and knocked me off my feet. Thankfully, I didn’t fall off the engine and called for the water to be shut off so that I could connect the extension to the base and complete the setup of the deluge gun. 

Lessons Learned

The incident occurred as the result of an honest mistake by the driver and me. I was in the habit of either calling for the deluge gun to be charged or having the engineer double check to ensure I had it set up prior to flowing water. Working with another driver who wasn’t aware of how our engine normally operated, I should have let him know that I was using the extension and would inform him when I was ready for water. Thankfully, I was only knocked down and didn’t suffer any injuries. Had he flowed water a few seconds before I had the deluge gun completely off its base, the force of the water could have easily knocked it into my face.  

Discussion Questions 

Of the 18 contributing factor categories listed by the Firefighter Near-Miss Reporting System in Figure 1, how many do you feel fall into the human factors category? Did we include categories that you feel are not human factors? Why or why not? 

Given the case study above, which factor categories contributed to this near-miss incident?


1. Putnam, T. (n.d, n.d n.d). Dr. (T. Mason, Interviewer) Bureau of Land Management.

2. Retrieved January 25, 2011, from National Firefighter Near-Miss Reporting System: http://www.firefighternearmiss.com/Resources/Annual_Reports/Active_Resources/2008_Annual_Report.pdf.
3. LeSage, P., Dyar, J. T., & Evans, B. (2011). Crew Resource Management: Principles and Practices. Sudbury, MA: Jones and Bartlett Publishers, LLC.; Carley, D. A. (2010). Organizational and Group Influences on an Individual in a Fire Department Company. St. Cloud State University. Fargo, ND: Fargo Fire Department..


Craig Nelson (left) works for the Fargo (ND) Fire Department and works part-time at Minnesota State Community and Technical College – Moorhead as a fire instructor. He also works seasonally for the Minnesota Department of Natural Resources as a wildland firefighter in Northwest Minnesota. Previously, he was an airline pilot. He has a bachelor’s degree in business administration and a master’s degree in executive fire service leadership.

Dane Carley (right) entered the fire service in 1989 in southern California and is currently a captain for the Fargo (ND) Fire Department. Since then, he has worked in structural, wildland-urban interface, and wildland firefighting in capacities ranging from fire explorer to career captain. He has both a bachelor’s degree in fire and safety engineering technology, and a master’s degree in public safety executive leadership. Dane also serves as both an operations section chief and a planning section chief for North Dakota’s Type III Incident Management Assistance Team, which provides support to local jurisdictions overwhelmed by the magnitude of an incident.

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