Managing a high-risk/low-frequency incident is something that Lexipol co-founder and risk management expert Gordon Graham speaks about regularly, underscoring the need to prepare in advance.
“If it is predictable, it is preventable,” Graham stresses about training for a variety of situations, including incidents that have the potential to place first responders in serious danger.
With Graham’s risk models as a backdrop, here we’ll address how can we operationalize a program that prepares incident commanders (ICs) to be successful when they are faced with a time-compressed, high-risk incident they have never seen before.
RPDM and “pulling mental files”
Graham emphasizes the importance of preparing for high-risk, low-frequency events by demonstrating that everything we do can be placed into one of the four boxes related to the level of risk and frequency of the event.
To make sense of these time-compressed, complex decisions, Graham regularly cites a model called recognition-primed decision-making (RPDM). The RPDM model is a common explanation of how fireground commanders can make effective decisions when faced with situations that we may never have seen before.
Think about it this way: Your brain is essentially a hard drive that is connected to a network of neurological sensors. The human head hard drive is always on. It captures the sights, smells, sounds and emotions from past incidents and stores them away in an easy-to-pull file. So, when you encounter a similar event, the network is quickly scanned, the hard drive reveals the information that is a close match, and you respond appropriately.
However, if you have not experienced the situation before or do not experience it regularly, then your brain cannot quickly locate a match. Without a match, the condition can deteriorate rapidly. No wonder it is the low-frequency events that cause tribulation.
Incidents categorized in the upper left box should be the most concerning to fire service leaders. The high-risk/low-frequency incident can create a mix of dangerous circumstances, particularly if time is critical. In cases where time compression does not exist, we usually do fine and muddle through the event. Example events include the emergence of a layoff threat, a budget cut, a personnel problem – those are less concerning high-risk/low-frequency events because time is not a factor. We can call a friend, do some research, reflect, perform a formal risk analysis, etc.
When there is not discretionary time, and a decision needs to be made immediately, the high-risk/low frequency area is fraught with danger. Most readers can probably remember an instance when they arrived on an incident that was not in their hard drive. The head hard drive just spins and spins and spins. The reaction time is likely quick, but you feel like time stops. Your anxiety level goes through the roof. Your neurological receptors continuously scan, searching for any piece of data that is recognizable. A similar building, roof system, extrication training, radio report training – anything to connect with a response.
I had a 5th-grade teacher who made it clear to us on day one that there was nothing that we could do that she had not seen before. She had over 30 years of experience that created a mega-drive of accessible experiences. So, on the day one of my classmates projectile vomited during a tornado drill, my perception of my teacher was that she had it all under control (and she even had a migraine headache).
Her immediate response in handling the simultaneous situations was an example of RPDM in action. She likely pulled from her mental file of past tornado drills, past vomiting children and even working through migraine, all to maintain her focus and make decisions that would contribute to a positive outcome.
But when the experiences do not exist, it requires leaders to develop their organization’s resiliency. Many of us are dealing with a large influx of new firefighters due to large numbers of retiring firefighters leaving the service. Unlike “The Matrix,” we cannot simply download experiences into new firefighters. We can, however, leverage key tools that are available to organizations.
Resilience through reinforcement
When leaders expect specific outcomes in high-risk environments, it requires the use of evidence-based protocols (think best practices) and applying systems thinking –understanding how systems influence one another within a whole.
The people with the most experience should be involved in developing protocols – some call them standard operating guidelines or procedures (SOGs/SOPs), policies, etc. – that identify all low-frequency occurrences that have been experienced in the discipline. Reach out to other organizations and ask for their protocols, query national organizations, and perform a literature search on the topics. Asking for help is not routinely how we do business, but it is how business flourishes. It’s called collaboration – and we need more of it!
Using protocols to develop a standard approach to high-risk/low-frequency incidents is necessary but insufficient to optimize performance. ICs must both learn the routine, especially in the low-frequency setting, and have opportunities to practice and reinforce.
There are many studies that support the initial training necessary to develop competency, but the most substantial challenge for incident management practitioners is to maintain the competency and expand the experience in the hard drive. We should not be training until we get it right; we should be training until we cannot get it wrong. That takes regular practice, permission to error and consistent learning.
Cognitive aids minimize error
When an IC is placed in a high-risk/low-frequency situation with time compression, the IC’s focus will momentarily shift out of the situation while their brain, using the RPDM model, searches for answers. When the IC returns to the situation without an answer, there is a higher probability of missing critical details. We are human, and skipping steps can become insidious. The details can be as simple as forgetting to make critical assignments or notifications that, without stress or time, would be second nature.
One way to minimize such human error in these situations is through checklists. Procedural checklists can improve performance through standardization and a reduction of the cognitive burden.
The volume and complexity of what we must remember, being an all-risk discipline with ever-changing regulations and standards, has exceeded our ability to manage incidents as we did 40 years ago. The days of a white helmet standing in the front yard in the environment, yelling commands and breathing smoke, are over. Having to be the answer to every threat has both kept us relevant and created massive burdens for fire crews.
Checklists allow the IC to focus on the technical aspects of the incident and commit cognitive energy on managing the event. Several checklists are integrated into tactical worksheets, passport systems and commercial software systems.
Designing checklists specifically for high-risk/low-frequency situations is a scientific process and needs validation and consistent use on all incidents. “The Checklist Manifesto” (Gawande, 2010) recommends that a checklist for sophisticated situations be used between five and nine items, which is the limit of working memory.
A checklist is only a job aid; it is not a cookbook. For complicated situations (like baking), the instructions in cookbooks follow a method predicated on time. The ingredients are the constant. The oven is preheated to 360 degrees, then add cream butter, sugar and brown sugar until it is nice and fluffy, then add two eggs and vanilla and beat for an additional two minutes on medium heat.
In high-risk/low-frequency events, the “ingredients” are variable (e.g., a train derailment with multiple hazmat cars) and time is not controlled. High-risk/low-frequency events are complex, meaning multiple systems are interacting simultaneously – and checklists serve as aids to manage the chaos.
Transparency and feedback
A culture of transparent, honest and uncompromising review of an IC and a team’s performance is essential for achieving and sustaining the optimal performance of any incident. Creating this type of culture requires the collection and dissemination of incident data and the delivery of objective, timely feedback to ICs, which can be addressed through a traditional after-action review (AAR) or a PLOWS (Plan, Leadership, Obstacles, Weaknesses, Strengths) review.
These reviews should encourage candid conversation in a non-threatening environment. Discipline should never be discussed or threatened during the review, and every member’s feedback and perspective should be shared. Above all, perspectives regarding the incident or event should be shared without the filter of fear. Oftentimes, perspectives vary greatly depending on variables like arrival order, assignment, location and task. For example, a firefighter’s perspective of a building’s condition may vary greatly from that of an external IC. When decisions are explained in the context of time and condition, we often can avoid the “armchair quarterback syndrome” that can hinder organizational growth and paralyze a leader’s future actions.
Standard AAR questions
- What was planned?
- What actually happened?
- Why did it happen?
- What can we do differently next time?
Ongoing training
For the identified and predictable high-risk/low-frequency incidents, a protocol based on evidence and supported by job aids and culture is essential to an optimal training environment. ICs can develop their comprehensive approach and confidence through deliberate training and reinforcement of the training. Confidence managing incidents through high-definition simulations that induce stress (time compression, real radio traffic, heat, flashing lights, high-definition video, etc.) leverages science to build RPDM experiences that can easily be recalled when necessary.
In the fire service, we can be reluctant to change. Everyone who intends on being an IC must participate in the initial and ongoing structured training with assessments. Only with evaluations that are honest, but non-threatening, can the system identify substandard performance, provide feedback and make improvements. Equally as important, participants can learn through experiencing all positions in the system during scenarios (battalion chief as a first-arriving officer, an out-of-grade officer serving as a battalion, etc.).
PREDICtABLE is preventable
Living in the upper left quadrant without having a file for the RPDM search can be scary, but like Graham, says, “If it is predictable, it is preventable.”
It is the responsibility of all of us, at every rank, to maintain a commitment to improve. Every shift, every incident and every interaction is an opportunity for learning. They are also a contribution toward the RPDM experience to file away for recall when needed.
When you change your mindset so errors change to learning opportunities, experiences become valuable and worth review, and when you commit to constant improvement, your performance will improve.
