Thinking About Fires – Part 1

AP Photo/Karl Mondon, Pool Carolyn Desmond is presented with a medal of honor by by Harold Schaitberger of the International Associaton of Fire Fighters during memorial services July 27, 2007 in Concord, Calif. Her husband, Engineer Scott Desmond, and Captain Matt Burton lost their lives July 21, attempting to save an elderly couple in a San Pablo fire.

There is something wrong with how we think about fires.

The report into a fire that killed two firefighters in San Pablo, Calif., last year was released this month. As often is the case, staffing is cited as a factor in the LODDs. Final reports such as this, the one from Charleston and so many reports produced by NIOSH make me wonder if the report writing is more catharsis than call to action, more procedure than learning.

Are these reports — created in the aftermath of tragedy — developed in some subconscious effort to soothe our souls by making sense of things? I ask this question because nothing ever seems to change. If reports of this type were useful, meaningful, or able to effect change, we should have seen the results long ago. As J.A. Thackaberry noted in a paper on wildland tragedies, “reports have become something of a post-mortem ritual.”¹

What the San Pablo report and others like it provide are the illusion of having regained control, vis-à-vis having the ability to explain what happened. However, the deliberation is not introspective and it denies the emotional aspects of what occurred. We have heard much talk about recognition-primed decision-making in recent years but what we don’t hear is that “the experiential system automatically searches its memory banks for related events, including their emotional accompaniments.” (Slovic, P. 2002)²

These reports only generate limited reflection; it is more like staring at a train wreck. I have said some pretty hard things here but the evidence is clear. If the messages were working, the National Fire Academy would not be producing PSAs to encourage firefighters to buckle up. The reports alone should have made the need for seat belts clear.

The reports allow us to ostensibly take apart another department from the ground up and from the top down in an elaborate attempt to discover what went wrong and to fix it for next time; to fix it for ourselves before the tragedy occurs to us. Unfortunately the next time still comes and the next report outlines similar errors. This can mean only two things: either report writing in the aftermath of a fatal fire is an ineffective mechanism for preventing future death and thereby a waste of time, or the fire service is unable to learn.

Of course the real right answer is probably some combination of both ideas. “There is a presumption that organizations are like machines whose problems can be decomposed into parts, the causes identified, and the fixes put in place. The ‘fixing’ orientation looks for linear cause-effect relationships, simplifies problems by decomposing them into well understood components, and applies specialized knowledge to create technical solutions.” (Carroll, J. 1997)³

I have not had the time to read every line of the latest series of reports, but I don’t think that I have to read the whole thing to get the idea. I know that they talked about staffing, command, communication, coordination, control; the same issues as in all the other reports. As Thackaberry notes about similar reports in the wildland world, "…there were ‘no startling revelations’ from this fire which seemed like an “eerie sickening synopsis of decades of disaster fires.”

I am sticking my neck out here but I don’t think that staffing killed those firefighters in San Pablo; I don’t think that a failure to follow the rules killed them either. I agree that staffing is important. And I agree that rules are important. Certainly a four-person engine can do more than a two-person engine. What I think gets firefighters hurt is that they fail to adjust their behaviors to the staffing level that they have. I think what killed those men is what has killed and injured so many before them — a failure to truly understand what they were up against, especially how quickly things can change. An analysis from Thackaberry in 2003 on states, “Two common factors among the string of tragedy fires they studied: firefighters didn’t realize that they were facing as dangerous a situation as they were; and, once they realized they were in danger, firefighters seemed to ‘forget’ the correct action they should have taken in the moment.”

Those firefighters were the victims of something bigger than fire; they were the victims of a system that was unable to provide an adequate mental framework from which a unit officer and/or firefighter under stress, making many rapid decisions, could access and apply to the situation at hand. The question is not what would have been different if there were four people on the first engine. The real question is what would have happened if the first engine had made some different choices. What if they were given adequate training in their personal and collective cognitive limits? What if someone told them that fighting fire was not a zero sum game and that more lives can be saved with better tactics than with the headstrong “aggressive interior attack.” I wonder.

During the San Pablo incident, a company set up a large fan outside the door and began a positive-pressure ventilation operation before a ventilation hole was made in the roof. Shortly after the fan was turned on, a buildup of the fire was observed followed by a backdraft explosion. I refuse to believe that the people who set up that fan that day wanted things to go bad. Everyone was acting in good faith but that was simply not good enough. But more important than that is the biggest lesson of all: what can I do different?

As you wade through what is a finely detailed report, some things are more striking than others, like the fact that three of the five metrics used to measure performance at the fire involved rules, policies, or procedures (page seven). The problem that night was not rules, it was a lack of effective coordination and communication. One cannot say that the rules for passing command were ineffective, because command was not passed according to the rule. But simply stating that the rule was not followed is only telling half the story. The more interesting question is why, and unfortunately we can never know that fully in the aftermath of an event like this death.

I am inclined to think about firefighter deaths in the line of duty as “normal accidents.” Organizational theorist and sociologist Charles Perrow introduced normal accident theory. It is based on the idea that some systems are so complex that accidents are inevitable or normal. While Perrow generally limited his discussion to technological systems, the theory easily transfers to other complex operations, including fire department operations. Administrators and chiefs tend to react to this growing complexity by creating more and more rules and working harder to ensure that the rules are followed. Unfortunately, as J. Carroll notes, “Such complexity obscures the impact of particular actions, and the invisibility of latent defects masks the state of the entire system…” That is until a firefighter dies in a house fire.

References:

Thackaberry, J. A. (2003, May) “Management, Drop Your Tools: Military Metaphors for Wildland Firefighting and Public Resistance to “Safety” Legacies of Tragedy Fires” Paper presented at the annual meeting of the International Communication Association, Marriott Hotel, San Diego, CA Online .PDF Retrieved 2008-06-28 from http://www.allacademic.com/meta/p111824_index.html

Slovic, P. et al. (2002) Risk as Analysis and Risk as Feelings: Some thoughts about affect, reason, risk and rationality. Decision Research.

Carroll, J. (1997) Organizational Learning Activities in High-Hazard Industries: The Logics Underlying Self-Analysis. Journal of Management Studies.