Learning from mistakes before they become tragedies
Non-punitive near-miss reporting can prevent serious injury or line-of-duty deaths by relying on the group’s collective experience
Gordon Graham here with some thoughts on “non-punitive close call reporting.” That is a bunch of fancy words for a simple concept: the importance of learning from the mistakes of others who are similarly situated, prior to the mistake ending up in a tragedy. Oddly enough, this was the theme of my graduate thesis in 1977 – 40 years ago.
One of the most influential people in my educational life was Chaytor Mason. He was a massive man with a personality to match and I learned so much from him over my tenure at the University of Southern California in the Institute of Safety and Systems Management program. He introduced me to the writings of Archand Zeller and from his writings, I learned about Herbert William Heinrich, a thinker from the 1920s and 1930s.
Mr. Heinrich was (and remains today) a very controversial fellow and there is a very interesting piece about his work on Wikipedia. Regardless of your position on his data collection, data analysis and research methods, as well as his biases, Heinrich posed a very interesting theory on the mathematical relationship between close calls, mishaps and tragedies.
Heinrich said that when the group makes 300 mistakes, 30 of the 300 (actually, he said 29 but let me make the math a little simpler by rounding up to 30) will end up in a mishap (sprain, cut, fall, bruise, minor impact, property damage only) and one of the 300 mistakes will end up in the “big one” – death or great bodily injury. Heinrich’s triangle lays out this relationship.
Before we go any further, let’s take a second to think about that “group.” In any occupation or profession, the people who do that job are part of a group. A motorcycle cop is a motorcycle cop; they all do essentially the same job. A SWAT cop is a SWAT cop – I don’t care where you work. A pilot is a pilot, a plumber is a plumber, a phlebotomist is a phlebotomist, a priest is a priest, a physician is a physician, and a popcorn maker is a popcorn maker.
When I was doing my graduate work, I was a motorcycle cop in the Central Los Angeles Area of the California Highway Patrol. I was part of a group of 50 motorcycle cops in Central.
We (the 50 in Central LA) were part of a bigger group, the 250 motorcycle cops in CHP Southern Division. And we (the 250) were part of a bigger group of 500 motorcycle cops in the entire CHP. We (the 500) were part of a bigger group of 1,000 motorcycle cops in all the law enforcement agencies in California. We (the 1,000) were part of a bigger group of 10,000 (and this number is an estimate because no one collects this type of information) motorcycle cops in the U.S. Finally, we (the 10,000), were part of a bigger group of all the motorcycle cops in the world (I will not even guess this number).
Why do I make this point? Because the bigger the group we can draw information from, the more knowledge we get to help us avoid tragedy.
Good, Better, Best
When a law enforcement professional is seriously injured or killed, we write about it, we talk about it and hopefully we learn from it.
Learning from deaths or major injuries is a good idea, but it does not benefit the person who died. The better idea is to learn from mishaps, like the aforementioned sprain, cut, bruise, minor impact or “property damage only” event.
We need to report these mishaps because they are much more frequent (30:1) and much less severe in nature. And after reporting them they must be documented. And then they must be studied to identify their causes. And then we must share that knowledge with others. But still, this is only a better idea.
The best idea is to learn from events that don’t even cause a mishap but are merely mistakes. Call them errors, lapses, omissions or anything else you want, but if you have a “close call” you need to share it with the “group” – the other similarly situated law enforcement personnel in your department and/or state, as well as on a national basis.
In my tenure as a motorcycle cop, I made a bunch of mistakes, one of which ultimately ended up in the “great bodily injury” event in 1981 where I managed to T-bone a 914 Porsche at speed and ended up getting hurt. A lot of motorcycle cops (hopefully) learned something from that event.
But long before that “tragedy” I had a close call with, of all things, a bungee cord.
In the spring and fall seasons, the temperature in Los Angeles would vary during the day from cold in the morning to warm in the afternoon and back to cold again in the evening. About 1900 hrs every day you would have to put on your jacket. During the warm hours, the jacket was “strapped” to the top of the radio box on the back of the bike with a couple of bungee cords that were affixed to the motorcycle itself.
So one evening I was “unstrapping” the bungee cord (leaning over the bike to do this) and the cord broke loose a bit prematurely and retracted rapidly in an upward direction, hitting me in the face directly adjacent to my right eye. It hurt like heck but that was the end of it. I learned something about the danger of a bungee cord that was not properly affixed to the bike and how to more safely remove the hook from the connecting point on the bike, and where my face should be when I am doing that task.
Had the impact occurred about an inch to the left, I may have lost my right eye, and everyone in the CHP would have learned from that event. Had it killed me (and that is a stretch, I know) every motorcycle cop in the state would have heard about that. But because it caused neither major nor minor injury, no one else benefited from the lesson I learned that day.
As you read this, hopefully, you are thinking about your close calls – forgetting that when you take a magazine out of a semi-auto pistol there is always a round in the chamber or the close call you had with a downed power line or with a dirty needle during a search. Or the time you put Armor All on the seat of your bike to make it shine a bit (yep, I did that one too – you learn a quick lesson about the coefficient of friction between your britches and the leather seat).
With this in mind, we must develop non-punitive close call reporting systems that allow us to learn from each other’s mistakes prior to them becoming mishaps or tragedies. This system can work within your department, or within a group of departments in the same geographic area, so we can take advantage of the greater volume of mistakes.
Optimally, we can learn from the whole group – all law enforcement professionals across America – and for that matter, perhaps we can learn from other countries.
I helped develop www.firefighterclosecalls.com and www.firefighternearmiss.com. Both sites have the same goal: an open forum where firefighters around the world (they are all part of the same group) can report on and learn from the close calls of similarly situated personnel without fear of embarrassment or discipline.
So why haven’t I created something similar for law enforcement personnel? The law of unintended consequences. I do not want to create a database that can be used by bad people or plaintiff lawyers who might draw conclusions from the data and use them against other members of the group.
Perhaps there’s a “techie” reading this who can suggest how we might be able to keep a national database out of the hands of those with less-than-good intent. Until then, however, we can start small. Every law enforcement leader can initiate close call reporting within their agency and encourage officers to talk about their close calls with their peers.
Further, if you’re a Lexipol customer, the information you learn and want to share with others who are similarly situated can be distributed through the Daily Training Bulletin system.
Take the close calls concept home with you and talk to your kids (and other family members) about close calls that you may have had – with the jack on the car while you were changing a tire, or lighting the water heater, or what happened when you mixed cleaning products to get a nasty stain out of the confined space known as the shower stall. We have all made mistakes on the home front that did not end up in tragedy, and this information needs to be shared with others.