Editor’s note: This article is part of a series. Click here for the previous article.
Gordon Graham here and hello again. Thanks for the continued emails and your kind comments about my work. I am so fortunate to do what I do and communicating with many of you from around the country is quite an honor.
Not to digress (and at the risk of angering my editor), but a couple years back I drove from Harrisburg, Penn., to Verona, N.Y., for a fire chief’s conference. The only available flights were a series of connections in Istanbul, Cairo and Tokyo. (Just kidding, but flying from MDT to ORD or ATL to get to SYR, all with close connection times, is not my idea of good risk management.) So I drove it, and my gosh what a beautiful state New York is. I had the same experience when I drove later that day from Verona to Burlington, Vt. The long drive up on the interstate to get across Lake Champlain was absolutely beautiful.
But enough of this flattery. As we continue this series of articles on “real” risk management, I must again remind you that most of what you do, you are doing right! My problem is when things do not go right, there are significant consequences. As we have discussed in the last few articles, if we can identify the specific tasks that have the highest probability of ending up in a tragedy, we can put together control measures (policies, procedures, protocols) to prevent these tragedies from occurring.
Rarely do we make mistakes on the high-frequency events, even when you factor in complacency, fatigue, distractions, hubris and risk homeostasis. Mistakes in any occupation or profession are more likely to occur on low-frequency events—the left two boxes on the above chart.
And frankly I do not too worry much about mistakes made in the bottom left box (low-frequency, low-risk) because even if it does not go right, the consequences are de minimis (I used to screw with my lieutenant by using that phrase in police reports).
Please note my use of the word “too” in the above paragraph. Mistakes on these events will rarely cause you major problems, but they can be an indicator of a problem lying in wait. People who make mistakes on low-risk events are more likely to make mistakes on high-risk events, so it is important to emphasize to your personnel that getting things done right on everything we do is important.
To be fair, not every error is going to generate a tragedy, but if you make enough errors sooner or later all the holes in the Swiss cheese will line up and you will have that perfect storm for a tragedy.
A basic rule in life is when the deviation becomes the norm, it creates a problem lying in wait. Dr. Tony Kern writes about this in his great work Going Pro: The Deliberate Practice of Professionalism. Kern posits that “excellence should be the norm, not the deviation.” These are words to live by. We must strive for excellence (aka “getting things done right”) on everything we do.
But back to the focus of this piece: Rarely do we make mistakes in the right two boxes. Mistakes are more likely to occur in the left two boxes. And my major concern is in the top left box—the high-risk/low-frequency events.
Please recognize that my concern about high-risk, low-frequency events is not limited to public safety operations. Over the past few decades I have done a lot of work for a lot of people in all sorts of high-risk occupations. I don’t care what your profession is—when good people get involved in high-risk, low-frequency events, they are much more likely to make an error. To be fair, not every error is going to generate a tragedy, but if you make enough errors sooner or later all the holes in the Swiss cheese will line up and you will have that perfect storm for a tragedy.
In my live lectures I talk about this extensively. But let me close this writing with this thought. When I joined the California Highway Patrol in 1973, the state gave me a revolver. If my recollection is correct it was a Smith and Wesson Model 10. For you young kids reading this, it was known as a “six-shooter” because it had six bullets.
After I learned a couple of things about life and knockdown power, I bought a S&W Model 19—also a six-shooter but instead of a .38, it was a .357 Magnum. I carried that weapon on duty for years, except on the days of formal inspections, when I carried my Colt Python with a combat trigger and combat sights and “magna-ported and magna-fluxed.” That always impressed the chief doing the inspections.
But in the 1980s the department decided we needed more firepower and they started a transition from the revolver to the semi-auto. Law enforcement agencies around the great nation made the same change. And guess what happened to the rate of unintentional discharges? That’s right, it went up. (And please do not call them accidental discharges; there is no “accident” involved here.) Why? For some period of time, the involved law enforcement personnel were “playing in the top left box.”
And that will be our focus in the next few pieces in this series, with the end goal of impressing upon you the importance of events that fall in this top left box. Thanks again for all you do.
TIMELY TAKEAWAY—Please start to think about what happens when we give people a new piece of equipment—a new type of vehicle with a higher Cg (center of gravity) or more horsepower, or even a different configuration of switches, levers and buttons that control the vehicle.
