BY CRAIG NELSON
Wouldn’t it be great if we all had psychic powers or a crystal ball that could tell us when and where the next fire service mistake, near-miss incident, or accident was going to come from? Wouldn’t it be great if you knew trouble was right around the corner? Although we don’t have a crystal ball, we can still make pretty accurate predictions about where future mistakes may occur by learning from past mistakes. By learning about what has previously gotten others in trouble, we can tell where our next mistake, injury, or accident is likely to get us in trouble. We all inadvertently do this by showing up at work, training, and by responding to emergency incidents. We may not think about it, but on every one of these occasions each us is building our own experience. After many years, incidents, and training sessions, a firefighter acquires a lot of useful information. Over the years, some of us learn the lessons quickly; others, like me, take longer to learn from a mistake. Either way, we eventually learn from the experience and are much better prepared for the next time we encounter a similar situation.
This process of learning from experience is important to helping us to develop into the wily veteran who seems to know everything, but it only exposes us to our own limited experiences. It exposes us to the experience of one person. What if you could gain the experience of many others and learn from them without having to make the mistakes yourself? Imagine how much more you could learn and how much faster you could learn! If you combined your experiences with the experiences of others on your crew, others in your department, others in our country, and others around the world, you could build a vast set of experiences.
In 1812 Napoleon was a successful military leader who had amassed control over almost all of Europe. Although Napoleon was allies with Russia, he set out to teach Russia a lesson for breaking his embargo with Great Britain. Since he had a large army, much power, and past military success, he looked at Russia and saw an easy target. He moved his armies into Russia. The Russians retreated to hold off a direct confrontation with such a large army. Napoleon’s large army had to travel vast distances over barren lands. In Russia, his army encountered food shortages and bitterly cold weather. The conquest began with around 500,000 troops and ended with about 20,000.1 (Moore, 1999) Years later, another dictator with a tiny mustache from Germany attempted a similar invasion that ended with similar results.
There is a quote from Harvard Scholar George Santayana that says, “Those who cannot remember the past are condemned to repeat it.” This not a cold, hard fact; it is more of a reflection, but there may be some truth to it. Throughout history, there have been military, political, and financial examples of people repeating mistakes previously made by others. None of the examples are identical, but there is much that can be gleaned from the similarities. A better version of Santayana’s quote might be, “Those who don’t learn from the past mistakes of others are likely to repeat mistakes they could have previously learned from.” When you work in an emergency scene environment, mistakes can be very embarrassing; more importantly, they can be costly: injuries, lives, public respect, public support, and property damage. We currently have the ability, the data, the technology, and the opportunity to learn about what has and hasn’t worked at emergency scenes in the past, and, of course, why these things did or didn’t work. All fires are different, but there are many similarities in our operations at them. On closer investigation, we can find the reasons for the mistakes, near-miss incidents, and accidents. These reasons are called “contributing factors.” The contributing factors are a list of reasons that caused something to go wrong or almost go wrong. If this factor is removed, the accident or near-miss incident would be averted. The contributing factors are fairly easy to find and learn from if you know what you are looking for.
When you gather enough information, you will find that there are not only similarities, but also some predictability in what we do at emergency scenes. The more data (information) we have, the more accurate our predictions become. Now more than ever, we have easy access to information. Everything we do is recorded in some way, shape, or form by computers: when we turned out, when we arrived, how we responded, what actions we took after we arrived, what we responded to, everything we said on the radio, and much more. Some departments and firefighters are even wearing/using their own video cameras. Even if you aren’t recording with your own cameras, a bystander or the news media are most likely doing it for you.
We have all of this information, but we often overlook it or just use it for entertainment purposes. For it to truly make us better, we must study it as a professional football player studies the previous week’s game tapes and statistics. In the fire service, we seem to do a great job practicing or repeatedly running the routes, which is important, but I rarely see firefighters studying their game tapes and statistics or those of others’ performances. We must think of the data we have as a tool, we use to help us do our job better. We must then practice with and use the tool to understand the data (information about our emergency response). When you start to tally the number of accidents caused by backing an apparatus or from not wearing personal protective equipment, you begin to notice trends in frequency. When the same mistakes, near-miss incidents, and accidents are occurring frequently, someone will soon get hurt again. We don’t even have to imagine knowing what the frequent or costly mistakes are. We will already know what they are if we “watch the game tapes.”
If we look at the information we have so far about what is actually causing our mistakes, near-miss incidents, and accidents, what do we find? We find that the majority of our near-misses are caused by dangers hidden within human factors: decision making, lack of situational awareness, and human error. This comes from data that we have from near-miss reports. Every day we are getting more information to help produce more accurate results, but it is not close to what would be ideal. We need every firefighter to fill out a near-miss report every time a near-miss is encountered. With more than a million firefighters, we should get at least a million reports every year if everyone filled out just one report. Now think about all of the training you have had in the three areas identified. This information says we need to focus more time and energy on the game tapes and what is actually causing our mistakes, near-miss incidents, and accidents.
As an individual, company, department, and a profession, we have the ability to review every incident. During incident review, we can identify what our mission was, what we did well, and what we need to work on. We can watch video if it is available. We can listen to the dispatch recordings. We can simply sit down and discuss the incident. Do you review all incidents where you did something and then identify areas, skills, or techniques that you could improve on?
As an individual, company, department, and a profession, we have the ability to work on the areas we have identified that need or could use improvement. This might include building skills that need practice, practicing with equipment we don’t use often, or learning about human factors. Do you train in the areas identified as those needing work?
As an individual, company, department, and a profession, we can share lessons learned with others to prevent them from making the same mistakes. As an individual, you can share lessons learned by filling out a near-miss report. As a company, you can share lessons learned with each other during a tailboard talk to develop better team cohesiveness. As a department, you can share lessons learned to prevent repeating mistakes in your jurisdiction. As a profession, we can share lessons learned to prevent repeating mistakes around the globe. Do you share your lessons learned? The more often we do this and the larger the scale we do this on, the larger the impact it will have on our profession.
Near-miss reporting is a great tool for sharing lessons learned. It is a tool we can use to collect all of our lessons learned in one place so that others can benefit from them. We are fortunate enough to have this tool already in place. The National Near-Miss Reporting System for the fire service can be found at: www.firefighternearmiss.com. If you have not seen it or are not using it, I would encourage you to start.
Where do our mistakes, near-misses, incidents, and accidents come from? The vast majority of our mistakes, near-miss incidents, and accidents come from human factors and human interaction. Data collected from the National Firefighter Near-Miss Reporting System reveals that the vast majority of our problems come from human factor areas on which we typically spend very little time training. Our lessons to learn from (our history) show that we should be training on the following:
• Situational awareness. Know what is going on around you.
• Decision making. Use the available information and choose a path.
• Human error. They are errors humans tend to make because of human factors.
• Individual action. This is something a person does without understanding the effect it will have.
• Communication. This pertains to sharing information.
• Equipment. These are the tools we use to do our job.
• Command: This refers to the system used to effectively mitigate incidents.
• Procedure: Included are developed protocols, techniques, and training to follow.
• Accountability. This means knowing where everyone is and what they are doing at all times.
Each of the areas listed is a category and can be broken down into specific examples of when trouble may be around the corner. By providing likely scenarios and discussing the examples, we can develop flags (warning signs) that can alert us that we may be about to repeat a near-miss incident or an accident from the past. When we learn to recognize these situations, we can change course before they occur.
George Santayana, The life of reason. Volume 1, 1905. The Quotations Page, Retrieved from http://www.quotationspage.com/quotes/George_Santayana/21
Moore, R. (1999). The Russian Campaign. Napoleonic Guide, Retrieved from http://www.napoleonguide.com/campaign_russia.htm
(n.d.). National fire fighter near-miss reporting system. Retrieved from website: http://www.firefighternearmiss.com/index.php/home