Tailboard Talk: Mistakes Even Happen to Firefighters: A Preoccupation with Failure

By Craig Nelson and Dane Carley

Today’s political climate in the United States challenges the fire service’s idea of providing an effective service in an efficient way. Fire departments cannot exist in the future as they do today because the citizens’ definition of a professional fire department capable of meeting their needs is evolving. We believe that the principles of a higher reliability organization (HRO) not only address the needs of firefighters by creating a safer work environment but also address the desires of the citizens for the fire department to evolve with their expectations. We begin exploring the first of the five HRO principles described by Weick and Sutcliffe (2007) in this month’s column.

Where We’ve Been

Thus far, this column described near miss reporting and root cause analysis in the context of human factors to develop a learning culture within a fire department. A fire department cannot learn without developing valid and reliable methods to measure progress; anything else is anecdotal, stories that are true to a given situation but are too specific to apply across a broad category. The same principles used by a learning organization to measure, question, and adapt apply to HRO principle 1–Preoccupation with failure. However, the previous discussions center on emergency operations. The HRO principles now move us into an organizational framework that brings independent systems into a comprehensive program, reaching across the department. This helps us apply lessons learned in one system across all of the fire department’s systems so that our various independent systems become interdependent.


Where We Are: HRO Principle #1: Preoccupation with Failure
Granted, a preoccupation with failure sounds terribly negative to a firefighter looking at life as a glass half full. It is, instead, a simple recognition that a fire department has not experienced all of the ways that its systems can fail. It is also a recognition that it cannot know all the possible ways they may fail in the future because of the variability of emergency response. (Weick & Sutcliffe, 2007, p. 3) Simply put, even though all firefighters are superstars (which we believe is one step below super hero and one step above rock star), we WILL encounter more accidents in the future. Firefighters understand this concept but resist accepting it for obvious reasons.
In essence, an HRO questions everything because a routine is only a solution to the last problem the fire department experienced but will likely not solve a future problem. Routine is necessary in skills (e.g., donning self-contained breathing apparatus or pulling preconnects) but routine in thought processes and decision making excludes possible alternative challenges and their solutions. Humans naturally seek out evidence supporting what they believe to be true, which is why valid and reliable measures of effective service are critical not only to an HRO but also to a department’s ability to provide effective services efficiently. HROs institutionalize principle #1 several ways including:
  • Recognizing discrepancies and exploring them instead of mindlessly categorizing them in familiar, comfortable places
  • Questioning an error over and over to find the root cause, which often lies in a fire department’s culture and practices
  • Collecting after-action reports quickly before stories of the various participants are “straightened out”
  • Reducing distractions constructively through delegation without losing situational awareness
  • Encouraging an un-simplification of operations by seeking out different perspectives, people with different backgrounds, and encouraging constructive, respectful feedback
  • Doing away with rigid hierarchical decision making and replacing it with value-based decision making that is dynamic and flexible
Weick and Sutcliffe (2007, p. 47) have flags enhancing failure detection. Driessen, Outka-Perkins, and Anderson (2005) found many similar behavioral flags (indicated in the list below with an asterisk) contributing to lower crew cohesion in their study, which led to entrapments (or, ineffective service). These flags include
  • Recent changes in supervision*
  • Issues delegated without follow-up
  • Lack of questioning attitude*
  • Missed steps in a procedure
  • Loss of collective situational awareness; not everyone is on the same page*
  • Staff spread thin*
  • Distraction*
So how does the fire service institutionalize the concept of being preoccupied by failure and address the flags to provide effective services? In reality, fire departments already have systems in place to address many aspects of the first principle; however, critical components of those systems are often lost in varying degrees. In our opinion, the fundamental behavior driving an HRO’s success with a preoccupation with failure is near miss reporting and root cause analysis in the context of human factors as discussed in the first articles of this column because a desire to learn is fundamental to HRO principle #1.
However, it is necessary to adopt changes that the fire service is likely to resist. For example, the hierarchy is so engrained in our psyche that even people who recognize a need for some flexibility often make an exception for the emergency scene. Obviously, some hierarchy is necessary to divide the workload and accomplish tasks. However, input from citizens and government leaders is critical on daily operations. Input from even the newest firefighter should be encouraged–rather expected–on an emergency scene. Fire departments should seek out input and opposing views at an administrative level to ensure the department is providing an effective service that meets citizens’ expectations. Likewise, incident commanders and company officers should expect firefighters to speak up. For example, when any firefighter (even a new one) feels his or her situational awareness is different from others–in other words, the firefighter has a gut feeling that something isn’t right–it should be expected that the firefighter will voice his or her concern.
The fire service spends a great amount of time and money weeding out candidates to develop a list from the cream of the crop. We hire firefighters with education, training, and experience who have proven through testing that they are the best. Then, we tell them not to speak because they do not know anything. Regardless of our best intentions, this behavior transfers from the training ground and fire station to the emergency scene. It is possible, in fact, it is likely, that a new firefighter has valuable contributions about something even the best fire minds in the business may have missed. An HRO seeks out these differing views and incorporates them into the fire department’s operations to improve effectiveness.
The last thought is counter to the current political climate; however, it is no less important. The fire service’s “can-do” attitude and positive values cause many firefighters to try to accomplish more work or take more risk than is realistic given the situation. Efficient staffing that is no longer effective complicates this by reducing our ability to delegate “distractions” appropriately. Firefighters are trying to pull hose and carry forcible entry tools at the expense of looking around the scene to develop situational awareness and asking themselves, “What will I do if this goes wrong?” Incident commanders are trying to monitor multiple radio channels, track resources, and make strategic decisions simultaneously because an aide is not available to assist. This leads to delegating without adequate follow-up; distraction, missed steps in a procedure (e.g., accountability); an inability to develop an incident action plan and share it with crews to improve collective situational awareness; and reduces the opportunity for feedback during the decision-making process.
Case Study
The following case study is from www.firefightersnearmiss.com . The near miss report, 11-0000155, is not edited. We were not involved in this incident and do not know the department involved, so we make certain assumptions based on our fire service experience to relate the incident to the discussion above.
Event Description
Just after midnight, a call was received from an occupant of a large building asking for assistance in securing a fire alarm, which was going off.. I got my driver and medic crew and proceeded to the building without notifying the shift commander, as I should have. Upon arrival at the facility we were met by a worker stating that there had been a smell inside for a few days and now the alarm had activated. He reported seeing no signs of smoke or fire as he left the structure.
My driver and I proceeded into the building with the civilian as an escort, due to the need for keyed entry throughout the building. Upon entry there was an audible alarm as well as a visual notification. We proceeded up to the second floor and into the computer area where the smell had been reported. At this time a haze was noticed at the ceiling extending down approximately two feet. The civilian said that when he left the room it was clear. My partner and I looked around the room for possible causes of the haze when we began to feel heat coming from behind us. I turned to my partner to tell him we needed to vacate the building when I noticed my voice had deepened and slowed considerably. I knew at this time we had been exposed to something.
A full commercial response was struck upon evacuation of the structure. The building was searched and found to have a circuit breaker taped open as well as having had a release of FM 200 in the computer room (an agent much like Halon). All crew members were medically cleared and felt no ill effects. The structure was released back to the occupants upon completion of operations.
Lessons Learned
I learned many lessons from this near miss incident. The first of which was a lack of communications to the shift commander. His lack of notification of where crews were and in what manner they were operating was cause for surprise and delay. Further learning occurred from not following the given departmental policies on alarm responses and staffing for entry into a structure with an activated alarm. While there were four personnel on scene, policy further states that a rapid intervention team is to be established where there are no imminent lives in peril. I showed a complacent attitude in not being properly prepared to enter the structure, establish command, and communicate to those outside. Another lesson learned was not to be disarmed by the civilian understating the possible problem and allowing myself to be lulled into a false sense of security.
Lessons were also learned in regard to the building itself. Being a secured government building, we had no real plans to identify possible hazards within the structure as well as the ability to access areas throughout. The light above the computer room door, identifying there had been a release, was not activated.
  1. Which bulleted points describing a preoccupation with failure above are relevant to this incident?
    1. Recognizing discrepancies?
    2. Encouraging an un-simplification of operations
    3. Lack of questioning attitude?
    4. Missed steps in a procedure?
    5. Lost, or even diminished, situational awareness?
    6. Distraction?
  1. A fire department’s preoccupation with error also enhances its effectiveness by capturing trends in data collection. What types of measures enhance a fire department’s effectiveness? Here are a few broad ideas, but each community has its specific needs.
    1. Identifying an emerging community hazard?
    2. Identifying an emerging building design hazard?
    3. Identifying services complementary to those already provided that meet citizens’ expectations and enhance responder safety while reducing the potential for future problems?
Where We Are Going
The next installment of this column discusses the second HRO principle – a reluctance to simplify. We would appreciate any feedback, thoughts, or complaints you have. 

Please contact us at
tailboardtalk@yahoo.com .

Driessen, J., Outka-Perkins, L., & Anderson, L. (2005). Two Entrapment Avoidance Projects: Studying Crew Cohesion as a Social Human Factor. USDA Forest Service, Missoula Technology & Development Center. Missoula, MT: US Department of Agriculture, Forest Service, Missoula Technology and Development Center.
Weick, K. E., & Sutcliffe, K. M. (2007). Managing the Unexpected 2nd Ed. San Francisco, CA: Jossey-Bass.

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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