‘Problems identified’ or ‘lessons learned’? Our choices make all the difference

Chief officers not only hold the keys to keeping members on track, they can make the choices that advance departments from talk to action


Much of the fire service’s history is rooted in the storied heroics of firefighters making death-defying rescues and braving near-unbearable conditions in service to our communities. And yes, some of that history is also rooted in the memories of fallen and injured firefighters.

It is unfortunately rare that these fatalities can be deemed truly unavoidable. In more cases than not, firefighters are killed or maimed in situations that we investigate and for which we ultimately develop a list of corrective actions in an effort to prevent history from repeating itself. We label such work safety investigations or after-action reviews (AARs), typically closing with a handful of lessons learned and/or those corrective actions necessary for the department to implement.

While lessons learned are often top of mind following tragedy, I submit that, unfortunately, we talk about lessons much more than we act on the recommendations. While there are many examples where events of the past have molded organizational growth, there are many more examples where we do a great job identifying the problems but fail to take the next step – turning lessons into culture or behavior changes.

"Whether dealing with an operational or personnel challenge, officers can find themselves in hot water when they fail to act appropriately," writes Bashoor.

The choices we make, the directions we take

Whether it’s the actions (or inactions) that create the need for the safety investigation or the potentially headline-grabbing personal or professional challenges we face, it is the choices we each make that determine the direction we take – and that mold the story told.

We all maintain the personal capacity to control our actions and choices. Similar to the organizational difference between “lessons learned” and “problems identified,” there are plenty of examples where this personal decision-making process manifests positively and, conversely, plenty of examples where it does not. It is how those choices manifest publicly that ends up telling the story – good or bad.

Whether dealing with an operational or personnel challenge, officers can find themselves in hot water when they fail to act appropriately. Whether in response to someone else’s choice or their own poor choices that need redirection, officers hold the keys to keeping us on track, especially through positive responses to the choices made. It is when we fail to act appropriately that we find ourselves off the tracks and scrambling to get back on.

Two significant incidents out of Maryland highlight how this decision-making process manifested in safety investigation reports:

  • 57th Avenue, Prince George’s County (February 2012): Seven firefighters were injured, two critically. The safety investigation report identified 46 recommendations. Staff members were directed to compare previous similar safety investigation reports to identify similarities. Astonishingly, 20 of the 46 recommendations were found in seven similar recommendations as far back as 23 years, including one LODD incident in 1992.
  • South Strickler Street, Baltimore City (January 2022): Three firefighters were killed and a fourth was seriously injured. A report analysis conducted a similar report comparison of seven incidents and found 16 similar recommendations in reports as far back as 16 years.

I was the chief of department for Prince George’s County in 2012 when the 57th Avenue incident occurred. While it is unconscionable to me that so many recommendations – significant recommendations – could go unresolved for so long, it is a reality that many departments would find similar results if they were to conduct similar comparisons. I took the position that this would not happen again, at least under my watch. While there were millions of dollars of needs and political challenges to implementing some of the recommendations, we charted a path forward and began the difficult process of recommendation implementation.

While the chief changed mid-stream after the South Strickler Street report release, the City of Baltimore has begun the process of implementing their recommendations. Making the recommendations a reality will be a challenge but fully within leadership’s power – it all depends on their choices, daily, monthly, yearly or however long it takes to get the job done.

[Read next: Beyond the report: How chiefs can drive cultural change after an investigation]

Public trust and public perception

Our choices aren’t solely related to operational incidents. Frankly, we find that our personal lives have profound effects on our professional headlines. Headlines aren’t titled, “John Doe did this or that” but rather emblazoned with “FIREFIGHTER John Doe …” or “PARAMEDIC Jane Doe ….” Yes, the choices we make are amplified, both good and bad. Whether we like it or not, as stewards of the public trust, we are held to a higher standard and should hold ourselves to that same high standard!

Remember, these headlines only appear as reactions to the choices WE make. We need to hone our personal and professional decision-making to ensure we’re doing everything we can to maintain the public trust and improve the public’s perceptions of the fire service. I encourage you to simply JDTRT (Just Do The Right Thing).

Whether it’s how we act or how we react personally or professionally, our choices will help define the story. Make sure lessons learned go beyond “problems identified” to actually affect change.

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