OK, the truth is out. Firefighters continue to die and get injured at fires. It would appear as if despite the best efforts of all involved, and there are a lot of people involved, the number is not going down. Anecdotally we are going to fewer fires and the logic seems to be that if we are going to fewer fires there should be fewer firefighter deaths. The logic is obviously flawed and the fatal flaw is that we continue to use static tools, outmoded systems of description and continue to apply “engineering” tools to what is primarily an artistic endeavor.
Arguably firefighting is part science and part art, but at 2 a.m. when a building is on fire, there is no time for logic and even less time for developing rational scientific models of what is to be done. The decisions that are made or not made during those critical moments are made by people, people who just woke up, and people who will not be fully awake or aware until it is all over. The science is still valid at 2 a.m. but the unit officer does not have time to think about it. Doing well in that environment is more art than science
I think that a reason the numbers of firefighter deaths has yet to see a decrease is because we have yet to find an effective way for firefighters to frame risk or to develop mental models of the problems they face. Our current pedagogy is simplistic. We:
- Create series of unsupportable imperatives; do a risk/benefit analysis, do a size up, communicate, etc.
- Offer firefighters static risk framing tools, with no narrative context
- Unconsciously develop a culture of unnecessary risk-aversion
What we need are new ways to think about what we do.
Unsupportable imperatives
It is not enough to say, “Do a risk/benefit analysis.” It is not enough to offer a tool like WALLACE WAS HOT as a mechanism for scene size up. That statement and that tool are both static in that they work well in a classroom but deny the realities of an emergency response. We cannot simply tell our firefighters that they must coordinate their actions, because coordination requires shared mental models of what they face. We should instead teach them to develop those shared mental models and from that coordination will follow.
There is a fog of uncertainty around every firefighting operation. Things move so quickly that we rarely remember all the facts in the aftermath. The further we get from the moment the more we re-frame what happened, fitting it into the framework of our expectations. Despite the inherent uncertainty, most firefighting classes, most SOPs, most rules force us into single minded and static approaches to dealing with emergencies; no wonder nothing changes.
As comfortable as we are with current fire behavior models and as talented as we may be at ventilation and other basic skills, each fire is intrinsically different. We cannot know what is stored in a house, which windows are open, or if there are holes in the floor. These things are uncertainties. We cannot prevent them, we cannot plan for them; we can only react to them. There is a time where the SOP becomes irrelevant.
“Unfortunately, what makes things work is often hard to articulate and harder to extract from the design as a whole. Things work because they work in a particular configuration, at a particular scale, and in a particular context and culture. Trying to reverse engineer and cannibalize a successful system sacrifice the synergy of success and the synergy of success. (1)
Despite what I put forward earlier, I do insist that SOPs are important and must be followed; that is unless the SOP is the wrong thing to do. This is a contradiction. The SOP is the framework that provides the rallying point for the development of shared mental models, but the SOP is not an immutable law.
Narrative context
Experience is the greatest teacher and in its absence the second best is a steady immersion in the historical narratives of those who have gone to a lot of fires. There is much to be gained from all those discussions about fires, the recaps, the myths, and the legends. In each of those narratives is a lesson that can be internalized and used as a memory aide when the listener is himself exposed to stressful situations.
Jon Sumida wrote, in reference to Alfred Mahan, that, "…many students of strategic history have mistaken the scaffolding required to construct the edifice for the building itself. They have thus not only confused the apart for the whole but failed to realize that he part so engaged was supposed to be discarded after the learning task had been completed.” (2)
We do this in the fire service all the time. At every level of instruction we push mnemonic, rules of thumb, and other simplistic tools for thought development. It is not working.
We must learn to listen to what has already happened and use that as a framework to prepare for what is yet to happen. This means that we must write often about what has happened, both successes and failures. We must develop a codified after-action reporting process free of mind numbing political agendas and free of the overly sensitive avoidance of placing blame. We must learn to live with error and to be comfortable saying that we messed up.
Standard operating procedures and mnemonics are the scaffolding that enables a fuller understanding of what the firefighter is to do. They are not, however, the ends. Once the learning has taken place, the SOPs can be disregarded when it is appropriate to do so, the pneumonics will become unnecessary and the risk benefit analysis will become automated.
“Things that succeed teach us little beyond the fact that they have been successful; things that fail provide incontrovertible evidence that the limits of design have been exceeded. Emulating success risks failure; studying failure increases our chance of success.” (3)
References
1. Success Through Failure: The Paradox of Design. Henry Petroski. Princeton University Press. 2006.
2. Inventing Grand Strategy and Teaching Command: The Classic Works of Alfred Thayer Mahan Reconsidered. Jon Sumida. The Woodrow Wilson Center Press. 2007
3. Success Through Failure: The Paradox of Design. Henry Petroski. Princeton University Press. 2006.
