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When Will We Ever Learn?

And hello again to all the visitors on the LA Fire Credit Union website and thanks for taking a look at my little corner of this site where I tend to ramble about things that may or may not be important to you, but for some reason I thought it was important enough to prepare and distribute to you. And over the last several of these pieces I have repeatedly thanked all of you for all your great work on the wildland fires around our Great State, and once again I must thank you – not for your performance on a fire – but rather your performance on the recent train wreck in Chatsworth.

I watched this incident unfold on TV and was very impressed with the professionalism of all the first responders – particularly the representatives from LAFD with whom I spent a lot of time when I was a street cop back in the 70’s. Whether it was a plane crash, a hotel fire, or an overturned big rig on I-5 (usually at the intersection known as the East Los Angeles Interchange – and usually involving a southbound trucker – talk about predictable) LAFD got things done right and watching your performance on the train wreck last week brought back a lot of old memories. But enough of the reminiscing.

I must get to the point of this brief piece before I run out of room. On June 1, I posted a piece on this site regarding collisions involving public safety vehicles that contained the following passage.

“I can tell you with certainty that every single traffic collision I have ever investigated where the firefighter was “Party One” was “caused” by a lack of sound professional judgment. To be fair there were many “subgroups” in this “lack of judgment” category including speed too fast for conditions present, inattention, failure to yield, not being aware of roadway idiosyncrasies, distractions, tunnel vision, cognitive lock, and of course the 800 lb. gorilla that no one wants to talk about honestly in our respective professions – fatigue.”

And to be fair, I was talking about apparatus related incidents – but you can certainly draw the link to the tragedy last week involving the train engineer who was “allegedly” texting some juvenile “train fans” slightly before the event. And to further beat this “distraction” issue to death, in the interim between this train wreck and today – there have been a couple of articles in the news about “texting” being a bigger problem than driving under the influence.

And to further beat this to death – and I will await reading the final report before I state this with certainty, but I wonder what role “fatigue” had in this terrible event that has taken twenty-six lives so far. One of the news stories stated that the engineer lived in Crestline – and while I don’t think I have ever been there I believe that is up on the “hill” and quite a ways from Chatsworth.

So let me see if I have this right. A speeding train (lots of lug nuts for those who have been to my programs before) traveling into the sun in the mid-afternoon with a distracted driver who may also have been very tired. And time for a chorus of “when will we ever learn!”

And as long as we are on this topic of “when will we ever learn” I just read a piece out of a Durham newspaper (isn’t the internet wonderful – and I invented it!) about a firefighter on a water rescue training exercise which ended up with a firefighter in critical condition because he was not wearing the safety helmet or life vest that department policy requires, nor were the two other firefighters conducting the exercise with him. Nor was the operator of the boat properly connected to the motor’s emergency kill switch.

According to what I have read (and I assume this “Durham” is in North Carolina), the firefighters were returning to their base when the operator of the boat tried to steer around some junk in the water. One of the three firefighters on board lost his balance because of this quick maneuver and started to fall out. The third firefighter tried to grab the one falling out of the boat but began falling overboard himself. When he tried to grab the fellow falling out of the boat he accidentally pushed the tiller (I have not heard that word in a while) and sent the boat into a turn so sharp that all three went into the water.

And can I have a chorus of “When will we ever learn?” And if you think I am picking on your profession here, I could ramble on and on and on about my former profession, law enforcement and all the crazy things that have happened because people don’t follow policy and procedure involving guns, vehicles, evidence, and a myriad of other things.

People, Policy, Training, Supervision, Discipline. I have been rambling on about these “Five Pillars of Success” for the better part of thirty years. I am convinced that most of the people in fire departments are good people. But having good people is not enough. Good people need good policy. And we have to make sure that the policies are known by our good people and that brings up the training pillar. And then supervisors need to enforce the rules. And when rules are not being followed – someone needs to initiate the discipline pillar.

My guess is that the Durham Fire Department (or whatever the agency name is) had the good people – and I will also surmise that they had policies in place regarding the operation of the boat in question. So what caused the tragedy? It seems evident (and again all the facts are not in) that the personnel on the boat somehow felt that these rules (kill-switch connectors, PFD usage, speed, and whatever else is relevant here) do not apply to them.

And I have no clue if they were arrogant (you can’t make me wear the PFD) or ignorant (I did not know we had a rule on that) or complacent (I have never had a problem yet) or what else may have caused them to think that “policies” do not have to be followed but apparently the rules were not followed and now we have a firefighter in critical condition and all of the problems that arise when that happens.

“Rules without enforcement are just nice words” – I have been hearing this since 1973 when I was a brand new cop but it bears repeating – again, and again and again. And I don’t care if it is the SCBA policy, the seatbelt policy, the backing policy, the “two in – two out” policy, or the harassment policy – rules need to be enforced. This is the mission of the supervisor – in my business the Sergeant – and in your business that Company Officer. These women and men need to assure that organizational “systems” (policies and procedures) are in fact being followed. Here is a thought for you.

“Show me a tragedy in the fire service and all too often I will show you the fingerprints of a Company Officer not behaving like a Company Officer.”

And for those of you who hold that job – please take this seriously. You have that daily and ongoing responsibility to assure that “systems” are being implemented. You have to love your people so much that you will make them follow the rules. Husbands and wives and boyfriends and girlfriends and sons and daughters and significant others are entrusting you with the safety of their loved ones. Please take your role seriously.

Well, that is it for now. I am preparing this piece at an airport and watching ground crews do their job – refueling planes, loading luggage, performing safety checks, and pushing planes around and I just hope that they are following all the rules applicable to what they are doing. Until I see you in person, please take the time to work safely.

Gordon Graham
Co-President, Lexipol

One Response to “When Will We Ever Learn?”

  1. Don Reyes

    Mr Graham, Thanks for the reinforcement. Sometimes we captains get to thinking we are “riding” our crew or “nit-picking” but you remind us of our duty and that that little feeling in our gut is there for a good reason.
    I just corrected a driver who was going to carry his coffee cup in one hand and steer with another! I often wonder if I am the only one correcting this type of error, but your article gives me solice that I am not alone.
    Thank You,
    Don Reyes
    CII
    LAFD

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