Fire Commander responds to article on increasing risk adversity in the fire service
Published: 10 February, 2012
"The missing component is the need to have a defendable process that clearly indicates the decision tree".
I found Roger A Klein's article quite interesting and almost consider him a brave soul to pen such thoughts in a society that is so much more 'risk averse' that from when I was a boy.
Each Fire Service manager brings with them a moral compass on how far they will go (or get others to go). The trouble is that each of us can be so different in different circumstances. I do reflect that I have done many things that in hindsight with my far greater experience I would no longer contemplate. I would explain this as "walking through a mine field without understanding the signs". I came out the other end not understanding the danger that I was in. I do however agree with this article in that there has now developed a significant mass of Officers that have a lower threshold for risk than what I am comfortable. I see some of these Officers certainly position their decisions at the extreme lowest end of the risk / reward equation. This is perhaps because the belief that their organisation would not be able to stand by them in the face of public criticism if things went drastically wrong.
In fact, this is very much that which Roger hints at. The reliance on procedure to the point that a manager can never be criticised for being too safe with his troops. "Don't do something" is a far easier decision than to "do something". The trouble is (again as pointed out by Roger) that we are seldom presented with all of the information and when you are aware of this there is always the suspicion that a nasty surprise is just around the corner.
We (in this day and age) do seem to be averse in making high-risk decisions, while keeping a clear monitor on the environment and being prepared to reverse these decision. To some people this is a weakness. It is not for me. I see the incident 'size-up' as a dynamic continuous cycle with feedback tempo more intense the closer we get to the "thin Red line".
Unlike some fire services that have adopted the terms Offensive and Defensive for the overall management of an incident, the NZFS has adopted this terminology as it relates to each crew. Therefore one crew can be tasked with a 'defensive, exterior attack', while another can be tasked with an 'offensive interior attack' at the same incident. An offensive interior attack is deemed to be at the higher end of the risk continuum and therefore there is an explicit understanding that there are enhanced supervision levels and IGC communications, with back-up (rescue) provisions and even heightened consideration of the choice of crew matched to the task. Further reducing the resultant risk by planning escape routes and contingency plans decided before entry. The safe person concept makes little attempt to change the initial risk to a resultant risk by applying mitigation strategies.
I feel for the managers that find themselves at the sharp end of criticism and perhaps having to defend their actions in courts based on decisions they made with only the best of intentions. The missing component is the need to have a defendable process that clearly indicates the decision tree they worked through to arrive at the decision to undertake the task. The police have a 'Continuum of Force' process that must be clearly articulated prior to the ultimate force of firing a weapon to subdue an offender. The Fire Service should have a similar 'Continuum of Risk Analysis' before putting troops in harms way. They must be able to answer the question: "Did you consider (at the time) using a taser and why did you discount that"?
Our problem, I believe is that this same process is not widely embedded in Fire Service doctrine. This continuum would narrow the margin between the risk averse and those that push the boundaries of risk regardless of the reward. I am sure those that are facing the judge would be more at ease if they could clearly articulate the steps in the Continuum that were covered off.
Any accident has a cause related to;
· An equipment failure (this went wrong because a pump failed)
· A procedure failure (the procedure said to do this but .....)
· A people failure (made up of):
- their underpinning knowledge (They didn't understand the risk)
- their Skill at undertaking the process (I just couldn't do this task safely)
- the attitude that they brought to the task (I was not in the right frame of mind to undertake the task).
Generally the Fire Service equipment is not an issue. The processes are often focussed as a risk averse doctrine (how can you write a procedure that could possibly put someone in harm's way), but the people component is the one that often results wrong decisions. My impression is that this focuses on three things:
· Unhelpful doctrine (risk averse basis with ((often)) glib reliance on the 'safe person concept' guidelines for the high risk decisions)
· Underpinning knowledge (and lack of awareness of what is likely to happen and lack of appreciation of what information the decision maker requires)
· Attitude (I just didn't give this enough thought, or probably "I see now that I should have given that task more thought")
Conclusion
My observation is that doctrine is written from a perspective of low risk. There is little procedure that gives an Officer some degree of comfort that if the likelihood and consequence equation goes wrong that they will not be accused of making a poor decision. I am reminded of an old saying, "often the only difference between heroism and foolhardiness is success".
Those decisions where there is little obvious hazard exposure and the chances of success are obvious, are easy. The same when the hazards are significant or overwhelming and the likelihood of success is obviously unlikely. However when we are working in that "no-man's land" between the two ends of this continuum where the decisions are the most difficult and yet a decision still needs to be made, we are in danger (as an emergency service) of losing our way.
We need to give more thought to this continuum of risk so an Officer can stand in court and say: "I went through these steps based on the information presented to me and I made this decision. Any reasonable person going through the same process would have assumed that the reality of what transpired and the resultant consequence of what happened was unlikely and therefore worth exposing firefighters to the risk of failure". Some would say the Safe Person Concept does this, I am not so sure.
Every procedure should not only give an Officer an obligation to say: "No, I chose not to commit any crew to that rescue (as an example) on the basis that the likelihood of their success and the consequence of failure was on the wrong side of the risk ledger". There also must be an obligation for an Officer to say: "Yes, the risk profile based on the information presented to me and the process that I have undertaken (the continuum of options) indicates that I must commit crews to this rescue". The result or outcome of that decision are now inconsequential to the original decision.
My observation in the current climate is that the Safe Person Concept and typical doctrine only gives an Officer an option to say "No", not an obligation to say "Yes" or better still that the "No" becomes a "Yes, if we .....". This in the hands of a Risk Averse Culture will change the effectiveness of emergency services.
Regards
Denis O'Donoghue, Waitemata Fire Area Commander, Auckland New Zealand
“Save or perish” appeared in Fire and Rescue issue 82, 2011.
To read the article click here
