If there is one certainty about any conference where Gordon Graham is speaking, it is that you are going to need a bigger room. That was definitely the case at this year’s International Association of Chiefs of Police conference where there was standing room only for Gordon’s presentation on the importance of knowledge sharing.
Gordon’s unique presenting style, designed to keep you entertained while he educates, is what attracts folks to his sessions and in this presentation, he delivered on that promise a hundred times over.
In the past several years, law enforcement has seen a wave of lateral transfers, retirements and resignations. With each officer who leaves your organization, knowledge does too. And even when agencies succeed in retaining officers, knowledge sharing is minimal at best – and rarely crosses agencies. When we are stuck relearning lessons, we fail to move our agencies – and the profession – forward.
During his presentation at the International Association of Chiefs of Police conference, Gordon Graham shared a passionate message: There is a way to make “the knowledge of all the knowledge of one.” By following his seven-step strategy to facilitate the sharing of knowledge by and between police departments, leaders will be better able to address and prevent issues before they become tragedies.
Memorable quotes about knowledge sharing
- “As a lawyer, I handle tragedy. As a risk manager, I study strategy and look for cause. If you can identify what caused the tragedy, then you can build control measures.”
- “Just because things end up OK does not mean that all ends well.”
- “The errors we are going to make can be predicted from the errors we have already made.”
- “We are learning individually, while the fire service learns collectively. If you learn something new, share it.”
A 7-step approach to making the knowledge of one the knowledge of all
During his presentation, Gordon shared his seven-step strategy to make the knowledge of all the knowledge of one:
1. We need better investigations. Graham suggests we adopt the NTSB approach to the investigation of our tragedies: “We need an independent, non-political, in-depth investigative process. Not to be rude, but law enforcement investigations of LODDs or OIS events are lacking in quality and information. We address the proximate cause but not the ‘root cause.’ We need to learn from our agency’s tragedies and ensure that we have appropriate control measures in place to prevent that tragedy from recurring.”
2. We need to learn from these investigations. How do you learn from the tragedies involving other law enforcement and fire agencies? Graham notes that there are resources like the Officer Down Memorial Page that shares causes of death such as “run off the road” or “shot by a suspect,” but wouldn’t it be nice to have a national repository of summaries of final incident reports that were easily searchable?
3. We need to learn from investigations in other high-risk industries. Graham suggests that law enforcement starts studying deaths in the aviation community. While the proximate cause is going to be different, the things leading to the incident are going to be similar to what happens in public safety. “There is a lot we can learn from the NTSB investigation of the death of Kobe Bryant in 2020,” Graham noted. “The final report goes well beyond the proximate cause and identifies the root cause so that other pilots can learn from it.”
4. We need to learn from close calls. During his tenure at the USC-ISSM, Graham was introduced to the work of H.W. Heinrich, a risk management guru of the 1930s. Out of his research came the concept of Behavior-Based Safety (BBS). Heinrich studied tens of thousands of injury reports (mostly prepared by supervisors) and concluded that 88% of them were caused by worker error. While many disagree with Heinrich’s findings, what we can learn from his research is that when a group of people does the same kind of job, such as patrol cops, they will make the same kinds of mistakes, where some will end up in a mishap, while others will end in great bodily injury or death. Historically we have learned from the deaths. Heinrich proposed that we should learn from the mishaps, that are way more frequent.
“It is best that we learn from the close calls,” Gordon noted, “and implement non-punitive close call reporting.”
5. We need to download the five percenters before they leave. If you give me 100 cops, said Graham, 10 don’t want to be there, 85 are good people and then there are 5 who want to change the world. Do you know who those women and men are in your department? Why don’t you catch those five percenters on their way out of the door? Identify those five percenters and ask them to think about the three most important things they did in each job description, how they did it then and how they would do it better if they encountered that event again. We can capture their thinking in small vignettes or “bitesize” training statements before they leave and use them in different ways as training tips.
6. Why don’t we bring the five percenters back? Akin to strategy five, let’s do something similar with great people who are honorably leaving our profession, suggests Graham. “When they announce their
retirement, give them an assignment prior to their date of separation: ‘Mary/John, you have had two different jobs in your career here, line and supervision. I would like you to think about the three (or more) most unique and/or important events you encountered in those two jobs. How did you perform the task when it occurred? And more importantly how you would do it better if it occurred again?’ Otherwise, when these people retire, everything they know goes out of the door when they retire. And while some/many of the five percenters will be unable or unwilling to “come back” in person, for those who are local and available and still remain true to the mission of the department and profession, offer them the opportunity to share their accumulated knowledge.
7. We need to put all this into a learning management system. Graham’s goal is to create a database where all of this knowledge is stored so everyone has access to specific improvements for their job responsibilities.
Related: LEO Near Miss initiative aims to improve officer safety
