We need to talk about learning lessons

Tony Prosser

Often there will be several underlying causes for an accident, leading to injuries or worse. The investigation of the cause of the event is critical for ensuring a repeat of the event does not occur in the future. Some industries and organisations are good at this, achieving enormous reductions in accident rates despite increasing activity levels in their field.

Compared to many high-risk sectors, the UK Fire and Rescue Service is slow in the extreme to share the safety critical findings of investigations with the sector or other organisations that may have an interest in preventing a similar incident in their industries. There is also the case to be made that property damage-only incidents should be investigated and lessons circulated about the efficacy of the strategies, and tactical and operational activities at the event. And the information on such lessons should be available in a timely manner so the lessons learned can be acted upon to try to prevent a repetition.

 

“Communications are a constant bugbear for the FRS and one of the three common criticisms made at debriefs of incidents”

 

Death of Firefighter Barry Martin

It is now 21 months since the death of Firefighter Barry Martin at the Jenner’s Department Store fire in Princes Street in Edinburgh and yet preliminary findings that may point to issues that operational firefighters may wish to consider at incident are not (at least publicly) available.

In the Fire Brigades’ Union (FBU) document, Firestorm: A Report Into The Future Of The Scottish Fire And Rescue Service (FBU, 2023), there is a mention of the Jenner’s fire, which is still “under investigation” by the Scottish FRS and the FBU. In Firestorm there is a comment that ‘a number of experienced, long serving firefighters have said that the SFRS has failed to implement in full the recommendations of the 2009 Balmoral Bar fire, which caused the death of firefighter Ewan Williamson, and that they lived in real fear of another incident of a similar magnitude’. It also reports that “recommendations made [in the Balmoral Bar Report] that were initially implemented have now regressed (sic)’.

The official report into the fire was published in 2015, six years after it happened; hardly a rushed report, and one would wonder if the perception of its importance (given that there were fundamental lessons to be learned about the physiological impact of heat on staff, operational procedures in basements wearing BA, welfare of staff and command and control that apply to all services) was diminished by the intervening delay. The period between the publication of the official report and the Jenner’s fire was more than seven years.

But what lies behind the loss of organisational memory and how could firefighters at a fire, less than two miles from the Balmoral Bar, claim lessons that should have been learned, or indeed were learned and possibly applied at the time, have now been forgotten? Before considering how lessons can be difficult to implement or are forgotten, it is worth considering some of the common failings at operational incidents.

 

Common Failings at Operational Incidents

Communications are a constant bugbear for the FRS and one of the three common criticisms made at debriefs of incidents (the other two, the welfare arrangements and relief deployments, are also critical for health and safety purposes but less obvious a risk to firefighter safety). The failings can run from equipment failure (at the Brightside Lane fire in Sheffield 1984 – the fire occurred the day before replacement radio batteries were scheduled: the radios ran out of power during the incident) or congestion and overloading the network, even where Airwave is being used. Moorgate (1975), King’s Cross (1987), 7/7 Attacks (2005) and Grenfell Tower (2017) all had examples of problems with communications that had an impact on the ability of firefighters to exchange critical information promptly. Sometimes this communications collapse has created problems in delivering a coordinated response and the passing of details of safety-critical issues. There are still a range of technical difficulties that could stymie or delay an effective intervention including dead zones and cyber attacks affecting the general communications infrastructure both between mobilising controls and mobile/on scene resources and also between individual units and staff on scene.

The foreseeability of potential risks to both firefighters and the community is not always possible. A multi-compartment fire in a high-rise building should not have been likely based on reasonable assumptions like a building being compliant to an as-built standard, and certified standard of fire safety and that the building would not be subsequently clad in a fully combustible material of “limited flammability”! Knowledge of a building’s construction and potential performance in a fire has been a gap in firefighter skills as the successful shift to home fire safety between 2000 and 2017 meant that capacity for inspection and holistic assessments of non-domestic and other buildings (including high-rise residential premises) was put on the back burner. The ability of firefighters to assess building risks has diminished and knowledge of special types of buildings – heritage, transportation centres, extensive warehouses, server hubs or even timber framed buildings (TFB).

How many TFBs are in an FRS area? Does anyone know – and what are the signs that a building on fire is a TFB that firefighters could recognise? Given the new government aims to build 300,000 new homes per year and given that many houses built in the last sustained mass housing programme in the 1960s and 70s were badly designed, poorly built and defective, it may be that an intimate knowledge of TFB will be become essential. This understanding is an important component of the firefighter’s role, but one that is perhaps viewed as less important in the 21st Century.

 

Lack Of Training and Communications

A common factor in many serious incidents involving firefighters is the lack of training and practice in procedures, particularly breathing apparatus (BA). The majority of firefighter deaths in the past 30 years or so have involved BA to one extent or another, perhaps reflecting the challenges of the incident type that require their use. It may also be partially a result of the increasing complexity of the procedures required to be followed: technical guidance for BA operational procedures (Technical Bulletin 1/1977 – 12 pages) now run to hundreds of pages and while comprehensive they appear to be less accessible – try finding a printed copy to read in a quiet room or on the beach.

In addition, national guidance is just that: guidance! In some parts of the UK, it is possible to have three or more services at a single incident with different BA policies, guidance and protocols (eg, search procedures), and even for high-rise buildings, different tactical procedures and interpretation of operational command guidance are in use. Is this a foreseeable problem at incidents or an acceptable risk? These are problems that have happened at incidents, are known about and need addressing at a national level. But there still appears to be a reluctance to have discussions on things that go wrong.

 

“A common factor in many serious incidents involving firefighters is the lack of training and practice in procedures”

 

Why is there a reluctance to address the issue of failures of an operational kind and why is the learning of lessons such an uphill struggle? The sector recognises there is an issue and talks about lessons being learned: in this the FRS is not alone – “we hear you!” is a common phrase heard now by politicians and organisational leaders in the private and public sectors and implies something will be done and sometimes it is. But many barriers prevent changes from being implemented quickly. This is where the lofty ideals are frustrated by human nature, organisational structure and inertia, as reality bites.

The complexity of incidents, large and small, means that although incident trajectories are similar, there will invariably be differences in circumstances, dynamics, environmental factors and other variables that can make it unique and require tactics and techniques to flex appropriately. There is also the changing nature of risks in the working environment.

Forty years ago who would have expected car fires that could not be extinguished with water, and remain a health hazard even when nothing is left to burn? There are likely to be more unforeseen problems as technology evolves. For example, data server warehouses are susceptible to several risks – high power demand and loading, high levels of security, size of the building sometimes several hundred metres in length and breadth, sometimes sub surface. What measures would be in place before a fire occurs in one – is the strategy to watch and wait for fuel-limited extinction processes to complete (ie burn out!)? As with most industries, the FRS will be behind the curve with new technology and developments.

 

 

 

 

Organisational Cultures

Organisational culture can have a great impact on the willingness of an FRS to adopt lessons learned to improve services – as most organisations tend to be resistant to change, particularly if there is a reputational impact in admitting where things went wrong. In that respect, a corporate FRS is no different to a watch at a fire station in avoiding professional embarrassment among peers and the public. The “keep it on watch/station/district/service” means the opportunity for the whole fire service to learn from the mistakes of others is often missed: mistakes made, which if publicised may save firefighters’ lives. Organisational inertia is also likely with the hierarchical layering and the governance arrangements which may slow progress down to a snail’s pace.

Underpinning all progress are the resource constraints from previous decades that are likely to continue for some time to come. New equipment, procedures and protocols take staff time (at least), which costs money. Few services have increased investment in research and development staff, and training departments, as authorities try to avoid cuts affecting the public-facing functions – fire stations and pumps (unfortunately, not crew numbers). It is another foreseeable risk not being recognised and addressed at a national level.

In fact, the opposite is true as wholetime staff losses in England alone have been around 25 per cent since 2010. Lack of effective training is also frequently cited as a crucial factor in accidents – the realistic training at a scale and of an appropriate quantum that is needed to compensate for the reduction in the number of incidents services attend is an almost impossible aspiration. And alternatives, including simulations, cannot replace the visceral experience of firefighting.

Organisational knowledge tends not to be retained in a structured approach. In many respects, lessons are passed down the generations of firefighters as stories, changed and mythologised, exaggerated and misremembered as the source of truth retires from service. Debriefs and lessons learned at smaller incidents – good and bad – are frequently not shared beyond a service, even where the lessons may have universal application. A national, open and accessible repository of key events and their lessons supported, not just vocally, but practically as well. Impossibly aspirational?

 

“The lack of a systemic approach to gathering, analysing, and openly communicating across the industry puts firefighters and the community at a heightened risk”

 

Arguments for not publishing the initial findings of an investigation into safety-critical events include having to wait until the inquest and criminal courts have followed their procedures. This does not happen in all industries. Take, for instance, the response to the two crashes involving the Boeing 737 Max on October 29, 2018 (Lion Air) and March 10, 2019 (Ethiopian Airlines). Within three days of the second crash, the Federal Aviation Authority (FAA) in the USA grounded all 737 Maxs for 20 months at enormous cost and inconvenience to all concerned (a cost of between $30 billion and $60 billion). While the comparison between a serious loss of life in a major accident and a single, nonetheless, serious fire and rescue incident (with a single serious injury or death) may seem excessive, the potential lessons learned are still immediate and in need of disseminating urgently and not taking six years for the findings to be reported.

The causes of a fatality or serious injury are often reported as equipment failure, human error or problems with management of the incident at a tactical, on-scene level. The wider organisational failures may not be identified as a problem because the focus is on one specific incident rather than taking a wider (macroscopic) view at the organisational, sector or national level to identify patterns of failures and their underpinning, root causes. Of course, any systemic or industry-wide problems will invariably need government action including funding and responsibility. Perhaps it is better left alone (“don’t ask, don’t tell” policy) and express surprise when (and not “if”) the next tragedy occurs. There can also be at the individual level, from firefighter upwards, a (real or perceived) fear of repercussions to report mistakes or safety critical near-misses due to fear of blame or disciplinary action that hinders the learning process and prevents lessons being shared and applied. In addition, there is the professional embarrassment of “fessing up to mistakes”. In the ideal organisation, an open culture that allows mistakes to be shared, lessons learned and improvements made, without such fears, should be embedded as part of wider cultural changes.

 

Learning Valuable Lessons

Other sectors have become more agile and adept at learning lessons from accidents, often applying lessons from one industry to another. At first glance, the similarities between activities in the aviation sector and medical surgery can seem remote and abstract. Kevin Fong, a consultant anaesthetist, and expert in space medicine, studied the aviation industry and identified the cross-industry similarities between aviation and medical procedures, while investigating safety in surgical operations and post operational care, where deaths were suspected to be above expected levels. His work emphasised the value of adopting strategies and methodologies from high-reliability industries such as aviation to reduce errors and improve patient outcomes. Among the features he identified was that aviation relies on protocols and a checklist approach to safety management, with standardised responses to both routine and non routine events to reduce human error. Checklists for critical steps in surgery have been found to reduce errors before, during and after surgery. Clear and open communication between aircrew is essential when in high pressure situations. Fong advocated a culture where all surgical team members, irrespective of position, can speak up to identify a problem and help prevent errors!

As to learning from lessons, Fong cited the aviation sector’s strong culture of learning from incidents with its thorough investigation processes and the cross-industry implementation of systemic changes to prevent reoccurrence. He recommended a similar approach for healthcare where mistakes are analysed to learn and improve systems and not assign blame, with a non-punitive reporting culture where near misses and adverse events are documented and studied to enhance safety.

For any industry that deals with high-risk activities, learning from experience is essential at an individual, organisational and industry level. The lack of a systemic approach to gathering, analysing, and openly communicating across the industry puts firefighters and the community at a heightened risk. Despite the systems already in place, with the potential to identify safety enhancements, the culture at national, organisational and individual levels is not yet at a stage where open discussions about things that have gone wrong can take place. Other industries can investigate serious accidents in a relatively short space of time – the aviation industry proves that. Why cannot the Fire and Rescue Service?