Tuesday, October 17, 2017

There’s Nothing Wrong with the “F” Word

(Photo: Pixabay/Geralt)
There’s Nothing Wrong with the “F” Word
by Riva Duncan

Failure: The neglect or omission of expected or required action. The Oxford Dictionary
Human: representative of or susceptible to the sympathies and frailties of human nature. Merriam-Webster Dictionary
(Photo: Pixabay/DirtyOpi)
Well, I don’t know what all of you might be thinking, but I’m talking about Failure. Yes, that “F” word. It seems we have become afraid to talk about failure. This word is something that is rarely used anymore in FLAs, reviews, etc. We dance around it; we tip toe across it like it’s broken glass; we use other words instead. In our journey towards being a learning culture in fire, I feel the pendulum has swung too far the other way. In the "bad old days" that many of us remember, serious accidents and fatalities resulted in investigations that seemed hell-bent on finger-pointing, finding blame. “Firefighters failed to follow the 10 and 18.” “’Can-do’ attitudes were causal factors.” “Managers failed to keep their people safe.” I’m not saying we need to go back to those dark days. No way. We’ve made great strides in looking for the learning; trying to get to the “why” and not the “who.” But we seem so afraid to talk about failures that I fear we are losing some of these tragic, yet rich, opportunities for learning.
Guess what? We as human beings are fallible. We make mistakes. All the time. It’s not right; it’s not wrong; it just is. So why are we so afraid to confront human failure? We talk about human factors. It’s something that gained good ground from Ted Putnam after his experience on the South Canyon investigation team. He was the first to bring up “human factors” and the “human dimensions” in decision-making in wildland fire mishaps. It was actually quite heroic at the time (he’s still one of my personal heroes). Putnam refused to sign the South Canyon report because he felt the firefighters were being blamed for being human beings in a life-threatening situation. Punished for “can-do” attitudes and exhibiting normal human behaviors in a time of severe stress. Putnam’s willingness to publicly speak out on behalf of the firefighters and jeopardize his career was a watershed moment in learning culture. It prompted the formation of the first Wildland Firefighters Human Factors Workshop in 1995. This was a Big Deal. In the paper that followed Ted Putnam wrote “The fatal wildland fire entrapments of recent memory have a tragic common denominator: human error.” (Putnam, 1995)

(Photo: Ted Putnam)
And so we set on a brave, new path. We moved away from investigations and moved toward “learning.” And it has been a needed and positive change. But have we now gone too far the other way? Have we become afraid to point out human imperfections, human factors, human errors in some of our accidents? In our intent to “honor the dead” are we reluctant to daylight normal human behaviors that resulted in bad outcomes?

I remember when High Reliability Organizing (HRO) came to the wildland fire community. The first of the five principles is “Preoccupation with Failure.” Folks had a really hard time wrapping their heads around that one, including me. “Wait, why should we be preoccupied with failure? We should celebrate our successes!” we cried. After sitting through the first HRO workshop in Santa Fe and then two more, I finally started getting it. If we don’t pay attention to the small failures, the weak signals, then we set ourselves up for complacency and the “temptation to reduce margins of safety…”

“When the five principles are violated….people fall back on practices that deny small failures, accept simple diagnoses, take frontline operations for granted, overlook capabilities for resilience, and defer to authorities other than the experts.” (Managing the Unexpected, 2007, Weick and Sutcliffe)

Being involved with the HRO workshops allowed me to accept the word “failure.” To treat it as it is defined. To not take it so personally (okay, I admit I’m still working on that). To look at it as an opportunity to examine not just my own failures but also the system failures of which I’m part.

We should seek “upstream” factors but also seek to acknowledge errors which may have occurred at the time of the event; our “system” has been built on the concept of redundant mechanisms, organizationally and operationally. We are almost always successful in finding ways to overcome the “upstream” factors. When we are not successful it is not just that the upstream factor contributed to the event, it is also a failure to adapt, improvise, and/or control the conditions the upstream factor created.

I certainly don’t have all the answers, and I try not to sit in judgement. This is really hard stuff. It’s a delicate topic—one with great potential to hurt people. But I also know there are numerous corner discussions, whispered conversations in small groups that delicately address the elephant in the room. Most people are extremely reluctant to speak aloud, and I get that. I know I have been.

Not that long ago, back when I was still married, I told my husband “If I die on a fire, I need you to accept that I might’ve screwed up. Take the life insurance, take the PSOB money, and move on with your life. Encourage folks to learn from my death, no matter how bad I might’ve messed up.” You all are my family as well. If I screw up and don’t live to tell about it, please learn from me. I give you permission to use the "F" word.

Putnam, Ted, (1995). Findings from the wildland firefighters human factors workshop (Technology and Development Program, 9551-2855-MTDC), Missoula, MT. USDA Forest Service.

Weick, K. E., and Sutcliffe, K. M., (2007). Managing the Unexpected, Resilient Performance in an Age of Uncertainty. San Francisco, CA: John Wiley & Sons.

Riva Duncan is an Interagency Fire Staff Officer and blog contributor. All thoughts are those of the author.

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