Editor’s Note: This article is part of a series. Click here for the previous article.
Gordon Graham here—thanks for tuning back in.
First, a quick recap. After some introductory comments in the first article in this series about the 10 Families of Risk, we covered:
External Risks – Legal and Regulatory Risks – Strategic Risks
As you go through each of these families of risk, ask yourself, “What are the three greatest risks we face in our department in each of these families, and what control measures (policies, procedures, systems) do we have in place to properly manage those risks?”
Our piece today focuses on Family Four—Organizational Risks. You may know that I am a lawyer. Lawyers handle tragedies. When something goes wrong, in any occupation or profession, lawyers do a great job of fixing it.
Please recall, though, that before I went to law school, I did my graduate work at the USC Institute of Safety and Systems Management. In this program, I learned about the big difference between “proximate cause” and “the problems lying in wait” that really cause the tragedy. I call these problems lying in wait for the “root cause” of the tragedy.
I have now spent more than half my life studying tragedies in public safety operations. And while there are thousands of proximate causes (the event that instantly preceded the tragedy), there are many fewer “root causes.” As noted in the chart above, in public safety operations the five most common root causes are PEOPLE, POLICY, TRAINING, SUPERVISION, and DISCIPLINE. Sometimes it is only one of these, sometimes more than one and sometimes all five of these root causes get involved in a single event and end up in tragedy.
Root Causes Illustrated
The number one cause of death in law enforcement operations is the same as the number two cause of death in fire service operations—traffic collisions. So, let’s use an example to show how root causes contribute to this proximate cause.
An emergency vehicle (police or fire) is en route to some low-level call for service—let’s use the example of a family pet stuck in a tree. The vehicle operator runs a red light and kills a child on a Vespa while simultaneously being ejected from the vehicle. This is indeed a tragedy, and from this event will flow the death of the child, injury to your operator, organizational embarrassment and loss of reputation, an internal investigation, civil liability and possibly a criminal filing against your vehicle operator.
Too often, when I ask people in the industry (law enforcement or fire) what caused the tragedy, they will default to the event that instantly preceded the tragedy and respond, “the operator ran the red light.” To be fair, that act of running the red light ultimately led to the involved tragedy, but what is the real cause?
The post-collision investigation lays out the findings of the investigators:
• People: The involved operator had an expired driver license, and in the last three years had been involved in four other preventable collisions. Yet on his performance evaluations for the last three years, he received accolades for good driving and “always setting the proper example.”
• Policy: The policy manual the officer had access to in the report-writing room states that when responding to call, always “proceed with due regard for your safety and safety of others” but says nothing specific about what to do when there is a red light ahead. During the investigation, it is learned that the chief had recently modified the policy to address red lights, but it was never updated in the policy manual located in the station.
• Training: There had been no formal training on vehicle operations in the past three years. Supervisors “discussed it with personnel” during scheduled ride-alongs, but there was no written documentation of that discussion.
• Supervision: The involved operator had a history of wanting to be first-in (the first person to get to the scene of the event). He also had a prior collision while rolling to a call. His supervisor says he discussed this bad driving with the employee several times.
• Discipline: Not one member of the department has ever been disciplined for an event related to vehicle operations. The involved department has the “worst claim record” in the insurance pool to which the organization belongs.
So there you have it, ladies and gentlemen. In future articles, we will spend some time on each of these root causes so that you can see the value of proactively addressing the problems lying in wait—prior to tragedy. Thanks again for reading, and please work safely.
TIMELY TAKEAWAY—Many of you have been involved in a tragedy similar to the one outlined in this article. And many of you have lived through “peeling back the layers of the onion” after the fact by the lawyers, the investigators, and the news media. When that happens, we repeatedly see the same problems lying in wait, and we discover that a lot of people knew about them and yet no one took action. The profession you have chosen is filled with risk—please take these risks seriously.