True Story

True story: On Sunday morning, the phone rang. A lady’s voice said, “I am a reporter from San Francisco. Can you clear something up?”

I responded, “I don’t know; what’s the question?”

“They had a huge fire here last night, on Saint Patrick’s Day,” she explained. “The fire department got there in two minutes, and the folks they cleared out of two bars on the first floor said the flames were 20 feet over the roof when they got outside. When we interviewed the folks from the bars, they said the top two floors were completely engulfed in flames when the firefighters arrived.”

“OK,” I said, “was anyone hurt?”

“No,” the reporter said. “But a city official who was there says the fire department took too long to pour water on the fire.”

I responded, “The firefighters got there in two minutes, no one was hurt, and they put the fire out? Then we win!”

The reporter continued, “But how much time are you supposed to take to pour water on the fire after you get there? What are the standards, the rules, the regulations for how long you should take to pour water after you get there?”

“Look,” I said, “I am sure you are a nice person, but this is a dangerous and dirty job. We show up and try to figure out what we have and what we can do about it with what we have. It is messy and fast, and if you don’t know what we are doing, you could never appreciate how much craftmanship and elegance are required to stretch hose, throw ladders, and extend a search for possible trapped or incapacitated residents.”

The reporter said, “That’s nice, but would you mind giving me some contact names who could tell me what the rules, the standards, the regulations are from the textbooks—about how long it should take—so I can quote them in my article?”

The aftermath of almost every significant incident leaves behind five things: a report, a new rule, a scapegoat, someone who now has all the answers to yesterday’s fire on the speaking circuit, and the slow death of truth. For us, if we follow all the rules and things go wrong on the fireground, the elites will cry, and those with no skin in the game will bemoan that we failed to innovate, deviate, and improvise. If we innovate, deviate, and improvise and things go wrong on the fireground, the elites will cry, and those with no skin in the game will bemoan we didn’t follow the rules.

How did we, our society, get to a place where when things go wrong—and they will—you are damned if you do and damned if you don’t? It has to do with a world view called high authoritarian modernism—big words for the modern view pushed by bureaucrats and elites who are not involved in the actual work but who can tell you exactly how you should do it or, in retrospect, how you should have done it. They also believe that rules and behavior controls can create safety and success in dynamically complex incidents where humans, who often are under incredible pressure, with limited knowledge, limited time, limited resources, time constraints, and goal conflicts, are expected to make decisions.

We see after-action reports where the words “failed to see this” or “failed to recognize that” because of some lack of skill or sometimes implied moral deficiency are ascribed as causal in the resulting bad outcome. The firefighter is bad, poorly disciplined, lacking, or substandard. It is always “human error”—or is it?

It is time to move on from this highly flawed view of incident analysis. Today, good folks are looking into better ways to try to understand why things happen on the fireground and other complex work environments where pressure, limited knowledge, and goal conflicts are present. It is especially important in safety sensitive work such as firefighting, commercial aviation, and law enforcement.

We know that no one comes to work at the fire service to do a bad job or to get someone hurt. We often hear speakers say really odd comments like, “We are killing 100 firefighters a year” or “We are still killing firefighters in the same ways.” This is nonsense. We are not killing anyone; firefighters get hurt, they get killed, and we did not do it. We are not killing anyone, and when they did what they were doing at the time they were injured or killed, they thought it was going to work or they would not have done it. It is called the local rationality principle, which means they thought their actions were rational locally, in the situation they were in.

The progressive authoritarian view, expressed by our reporter and city official, is very common. Many in the general public feel that all work can be boiled down to a simple set of directions like assembling a piece of so-called “some assembly required” furniture. This view fails to recognize the craftmanship, the skill, the talents, and the workmanship of the experienced and well-disciplined firefighter. There are even some who feel within our own profession that all you need to do is follow the rules and nothing bad can happen.

The infantilization of firefighting is reflected in the growing number of rules and regulations and now the advent of behavioral standards for the fireground. Lost in all this is the truth—that firefighting requires highly trained, highly talented craftspeople who, when necessary, can deviate, can innovate, and can improvise. We must always recognize and respect the intentions of the firefighter who, in context, made a decision that he thought would be successful. We must honor the intention regardless of the outcome—in fact, despite the outcome.

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