Wednesday, February 8, 2012


Fireground decision making is a critical factor in the outcome of any incident.  Fireground accidents are most often the result of a series of small cascading failures - both tactical and strategic - that lead to a major accident.  Every error compounds the next - this is also known as the sand pile effect.  

Many things can influence what are often construed as errors in judgement.  Errors in judgement can be influenced by both internal (emotional) and external (distractions) factors.  With the benefit of hindsight, it is easy to dissect the actions of others who came before and form an opinion, deciding on a better solution to the problem.  It is even easier when you have the test group to learn from.  

In retrospect, predictable certainly is preventable.

Some theorists, such as Charles Perrow the author of "Normal Accidents: Living with High Risk Technologies," suggest that accidents are simply a part of the natural order of things and cannot be completely eliminated.  In his book he describes systems and their interactions. "A complex system exhibits complex interactions when it has: unfamiliar, unplanned, or unexpected sequences that are not visible or not immediately comprehensible."  Perrow’s description of a complex system sounds an awful lot like the fireground.

Perrow goes on to describe complex, tightly coupled systems.  "A complex system is tightly coupled when it has: time-dependent processes which cannot wait.  Rigidly ordered processes (as in sequence B must follow A). There is only one path to a successful outcome. There is very little slack in the system- requiring precise quantities of specific resources for successful operation." By Perrow’s definition, the fire ground is a complex, tightly coupled system. Perrow’s "Normal Accident Theory" suggests that in complex, tightly coupled systems accidents are inevitable.

It's all about how we recover.

Organizations cannot train for unimagined, highly dangerous, never before seen situations. Close call and Line of Duty Death (LODD) reports are definitive learning devices; we are foolish if we do not examine them. The message that our fallen comrades are sending us through the reports is, "Don’t do what we did. Learn from our sacrifice."  It’s been said that it is unfortunate that we only get to die once, for there are so many lessons to be learned in death.

Aggressive fire companies do not make mistakes in the heat of battle- they make decisions. Decisions are based upon the best perception of the environment at the time. This is why being acutely aware of the environment and possessing the ability to adapt to changing conditions are vital.
 Preparing is itself an activity and action is preparation.
Keeping in mind that fire ground decision making is done in seconds with an endless list of often unknown variables is essential to the learning process- to honor the memories of our brothers and sisters who precede us in death we must study their every action to aid in preventing the same catastrophe again. Failure to learn from tragedies in the fire service means that we are destined to keep reliving these “unexpected” circumstances in a terrible reality production of ground hog's day.

If we continually study accident reports and learn from them, the lesser the likelihood of being surprised. Peter Leschak writes, "In fire and other emergency operations, you must not only tolerate uncertainty, you must savor it or you won’t last long. The most efficient preparation is a general mental, physical and professional readiness nurtured over years of training and experience. You live to live. Preparing is itself an activity and action is preparation."
Know what you can do and what you can't do.

Training and repetition are keys to avoiding potential errors in judgement. Captain Chesley Sullenberger speaks of the value of preparation in his book "Highest Duty". Sullenberger writes, “You can’t be a wishful thinker. You have to know what you know and what you don’t know- what you can do and what you can’t do. You have to know what (you and) your (equipment) can and can’t do in every possible situation."

Sullenberger is saying that we must train and constantly plan. Procedure, training, and planning are certainly important, but a rigid adherence to a plan that is not befitting the changing conditions can be suicidal.  Those who survive in high-octane environments are those who can anticipate changes in the environment and adapt accordingly.  They are the ones who can think and function under pressure.

Know the rules. Know yourself. Remember, the game is about vigilance and preparation.

Think about it.

No comments:

Post a Comment