We’ve likely all heard the saying, “100 years of tradition, unimpeded by progress.” While many vocations have lamented that phrase as a marker of their situation, we all know those people in the fire service who use “tradition” as the daily rallying cry to fight change, aka progress.
I have always embraced our fire service traditions, whether in training, education, development and the all-important story-telling. But for this article, I want you to focus on the areas where I believe it is most important to use tradition: education, training and development. If we’re ever going to improve on the 16 Life Safety Initiatives to bring everyone home, then it is imperative that we LEARN from the past and not LIVE in the past.
Evaluating incidents and sharing information
The real key to the discussion we’re talking about today is progress. All the tradition and development in the world won’t mean a thing if we don’t make forward progress from what the past has taught us. The day you think you’ve got nothing to learn from yesterday’s incident is the day you need to retire.
Are you conducting tailboard critiques, hot washes or formulating after-action reviews (AARs)? How about using random or incident-targeted quality assurance (QA) reviews on EMS-related incidents? And mind you, I’m definitely NOT talking about the AARs that seem to always be, “Everything went great and everybody did what they were supposed to do!” While it’s certainly possible to run a good call, PLEASE be honest with yourself and your people. How many of your bigger incidents truly fall into that “everything went great” category?
Even if you are conducting the critiques, hot washes and reviews, how are you using the information gleaned from those sessions? Are these one-on-one or one-off events that get hidden behind some cloak of personnel secrecy or HIPAA-related fears, or do you find ways to share information to help others not repeat the same mistakes—or better yet to hopefully help others emulate the successes? Sharing the information you glean from these types of reviews is actually more important than conducting the review itself. I especially liked sharing tailboard critiques because the information is fresh in folks’ minds. They’re more likely to provide accurate and frank information when it’s fresh and relative to what they’re doing at the moment. Once they’re done, share and then move on; don’t live there. And “move on” does not mean “check the box”; move on means take necessary steps to retrain, develop or document the success, share the information, and be ready for the next one.
Our electronic age makes it easy to create a template for sharing applicable reviews. When I worked at our academy, one of my missions was to produce “Fireground Updates,” which were mini-AARs, conducted with pen and paper, using information collected on scene and validated with incident commanders (ICs). We then shared the updates, including hand-drawn maps and visuals of scenes for the entire department to study and learn from. Imagine how much easier that is today with so much technology at our fingertips. The excuses to NOT conduct, produce and share these reviews are certainly limited with respect to time constraints—no more “but we didn’t have time.” And there’s always a HIPAA or an investigative nexus that has to be considered before releasing information. However, I submit that this should be a regular formality of approval, rather than a normal excuse to prohibit the release and sharing.
Learning from a serious incident
How about Safety Investigation Teams (SITs)? How often are we formally investigating what happened at an incident? Please don’t waste our time with the intellectual hypocrisy espoused by those who claim that “everything always goes right” or “everything we’re doing now is right, so we’re not going to change.” We all have something to learn from each other—and from EVERY call we answer. Similarly, we have the responsibility to use what we learn to help our people and our agencies to be better people and safer, more productive places to work. Incidents rising to a formal investigation level are much more likely to have a valid reason that prohibit or discourage sharing the information publicly. That’s a concern that MUST be addressed with appropriate legal entities before you find yourself in trouble. Once again, however, I submit that we have much more to lose by holding than by sharing.
For me personally and professionally, sharing successes AND failures is a solemn responsibility that was vividly highlighted in the experiences surrounding the 2012 Riverdale Heights 57th Avenue Fire. In that 1,000-square-foot single-family home fire, seven firefighters went to the hospital—two of them in initially critical condition. This was a condemned and vacant home we never should have entered, although the fire department was unaware of the condemnation, and there were vehicles and toys strewn around the yard. Six of the firefighters were released within a few days; the one remaining firefighter nearly lost his life. There were indeed things that went right that evening, but there were MANY more things that went wrong.
While 57th Avenue should have been a typical “bread-and-butter” fire for us, the results were anything but. I’ve covered the incident specifics in other articles and through release of the SIT report (http://pgfdpio.fireemsblogs.com/wp-content/uploads/sites/57/2015/02/SIT-6404-57th-Ave-Report-Final052913.pdf), so the focus herein is specifically about learning from the past and making forward progress.
Immediately after the incident (simultaneous with many other tasks), I ordered the formation of a SIT and a formal investigation began. This would not be a cookie-cutter SIT. Internal, external, local, regional and national contacts and industry experts were gracious to accept invitations to participate in this report. The formal SIT and report formulation lasted for 14 months—plenty of time to forget about it or keep it front and center. I chose front and center, every day.
The SIT report provided a painfully honest and stunningly accurate incident assessment and organizational roadmap for PROGRESS. Then what? Probably the most telling outcome from this report was the subsequent comparison of the 46 recommendations based on similar SIT reports we could find over the previous 20-plus years.
Remember how I said we need to educate, train and develop from our experiences of the past? Well, apparently, we only learned about 56 percent from our past. Twenty of the 46 recommendations were found on previous SIT reports, including at least one line-of-duty death (LODD) fire. Yes, that is absolutely unacceptable, and I will just about guarantee that most departments will find similar results if they’re truly honest about completing a similar analysis. You always hear people say, “Those reports just sit on the shelf.” Apparently, that was an accurate assessment for us! It is less an assessment of who’s chief than it is the assessment of the revolving door at the chief level, essentially de-prioritizing progress on “old issues” in favor of new ones. The average length of time for a chief at that point was 2.8 years. Fortunately, I made it past 6 years and was able to have an impact reversing this “tradition” trend. It is very important to note how the luxury of time was absolutely necessary to accomplish the things we accomplished. Literally years of preparing budget justifications and finding the funding to get things done. Very few of the progress points implemented after this SIT were done overnight; years is the operative measure.
Significant injury and LODD incidents are matters of crisis for an organization. How the organization acts and reacts to the outcomes may mean the difference between lasting change or the continuation of a ticking time bomb. For me, I wanted to ensure that 57th Avenue report was THE turning point for the department. Before my retirement in 2017, the majority of the 46 recommendations had been implemented (or were actively in progress). This involved significant investments in SCBA ($12 million replacement), changes in tactical procedures and orders (the use of flow-path management), changes in command and control (standardized command chart, rapid-intervention team checklists, and chain of command), implementation of closest unit response (automatic vehicle locator) as opposed to “first-due areas,” riding position radio deployment, and many more. There’s still more work to do, but the department is making progress, not dwelling on the failures, not “living in yesterday.”
I challenge you to complete the same analysis on YOUR previous SIT report recommendations. If you find that every recommendation has been implemented and not repeated, then please share your success story. I suspect the majority will not have that experience, though.
Time for progress
Educate, train and develop based on your traditions and your past. For your sake—and that of your organization—this cannot translate into a bunch of reports done by those “old guys.” If you want to have real impact, don’t dwell too long on the past; make sure you make progress. Don’t let these reports and investigations become part of a nebulous environment, where people hang out saying “nothing will change.” Educate, train, develop. Progress happens today and tomorrow, not yesterday.
Marc S. Bashoor
MARC S. BASHOOR joined the fire service in 1981. In 2017, he retired as fire chief of Prince George’s County, MD, Fire/EMS, the largest combination department in North America. His progressive community-based approach led to record hiring and a strategic apparatus replacement plan.
Twitter: @ChiefBashoor
Email: [email protected]
