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6 strategies to prevent tragedies

How PDs can learn from past incidents to take safer steps forward

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This article originally appeared in the June 2021 Police1 Editor’s Picks newsletter. Click here to subscribe.

The aviation community is big on sharing near misses, yet the public safety community does not do as well. As a result, we make mistakes that others in similarly situated organizations have already made, and, surprise, we end up with the same tragic outcomes.

In this roundup, I share six strategies with accompanying resources that we can employ in law enforcement to avoid death, major injury, embarrassment, lawsuit, indictment and loss of public trust.


Identify the root causes of tragedy

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Law enforcement must identify the root cause(s) of what really led to each tragedy.

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There are many reasons public safety agencies need to investigate (not document but investigate) tragedies.

Depending on the type of incident the investigation may include criminal prosecution, civil liability, internal affairs and the all-important lessons learned. But if not done correctly, we learn very little. Investigators must get past the proximate cause (the event that instantly preceded the tragedy) and identify the root cause(s) of what really led to the tragedy so we can ensure we have sufficient control measures in place to prevent similar events from recurring.

In 2017, the Johnson Foundation at Wingspread and the University of Wisconsin Law School hosted a conference titled “Best Practices for Review and Prevention of Deadly Incidents in High-Hazard Professions: Lessons for Police” as the first step in designing a statewide system for law enforcement to learn from past incidents. A summary of the conference proceedings is available here and can be used as a starting point for similar discussions in your state.

Read and analyze after-action reports


After-action reports should be designed to be read not stored on a shelf.

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Having the “investigation” up on the shelf someplace is of no value, but the length of many after-action reviews prevents many from reading – even the executive summary is often too long.

Investigators should list lessons learned in the initial pages of the after-action report so public safety leaders can quickly peruse the key points – and then have supporting materials available if they choose to read this additional information.

This article by Police1 and Lexipol Editorial Director Greg Friese is a good example of a concise summary of an after-action review coupled with action items that can be immediately implemented into an organization’s operational strategy.


Take close calls seriously


Learning from close calls is important for all public safety disciplines.

We must also learn from close calls.

What type of investigation is done when a suspect shoots at an officer and misses? Had the suspect killed the officer, there is a massive investigation with (hopefully) lessons learned. If the suspect misses the officer, the investigation is usually only for criminal prosecution against the suspect, and we learn nothing about the event. We cannot rely on luck – we must rely on process – and close calls (aka near misses) need to be investigated also.

In 1998, I co-founded FirefighterCloseCalls (FFCC) with my good friend Fire Chief Billy Goldfeder to bring forward the issues involving injury and death to firefighters. Since that time, we have highlighted thousands of firefighter close calls to prevent history from repeating itself.

The National Police Foundation recently established a similar program called LEO Near Miss. This is important work public safety should embrace.

Capture institutional knowledge


Capturing institutional knowledge before it leaves your agency should be the goal of every LE leader.

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Individually we know something; collectively the group knows everything. We must have a process to capture the knowledge that is learned every day by our personnel. Frankly, I learned quite a bit by hanging out with fellow officers off duty and listening to them talk about their daily experiences.

If every agency was to ask personnel planning to retire what were the three most important things they did in each job they had with the agency, how they did it and, if faced with the same incident again, how they would do it better next time, we could easily build a nationwide database for future review and sharing.

In August 2020, Police1 launched its Institutional Knowledge Project to serve as a repository of lessons learned around the management of people, policy, training, supervision and discipline that can be applied by future generations of police supervisors and leaders when handling similar situations. Click here to participate

Retain and train

Learn from those leaving


Consider bringing back retired cops to serve at your agency.

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Every year we have great people retiring – people who truly were excellent employees. Post-retirement, when is the next time we ask them for their advice? In too many organizations, the next contact is their funeral. Their institutional knowledge goes out the door with them. Perhaps we could bring them back to help train, mentor and develop current personnel to help them learn lessons from the past to prevent tragedies from occurring.

In April 2020, Police1 asked retired cops if the rehiring process could be expedited, would they be willing to serve during the COVID-19 pandemic to fill critical needs? Fifty-nine percent of respondents answered “Yes!” Police1 columnist and RAND researcher Bob Harrison followed up with an article on how agencies can reactivate retirees for police service in times of crisis.

Retired cops could fill gaps in current police staffing, while also fulfilling their desire to serve their communities.

Make every day a training day

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Now that we have great investigations and knowledge from close calls and lessons learned from retiring people, how do we deliver it to current personnel? We must train every day and the training must focus on the specific tasks in each job description that have the highest probability of ending up in tragedy. Make it your goal to identify these specific tasks in your specific job – and make it your goal to train and train and train. I know this is not required by law or policy – but remember that minimum standards are simply that – minimum standards.

Dr. Tony Kern (the smartest person I have ever met!) has a book called “Going Pro – The Deliberate Practice of Professionalism.” He preaches that we must make “excellence the norm and not the deviation” and shares a six-step approach to achieving that goal. Check it out here.

Gordon Graham has been actively involved in law enforcement since 1973. He spent nearly 10 years as a very active motorcycle officer while also attending Cal State Long Beach to achieve his teaching credential, USC to do his graduate work in Safety and Systems Management with an emphasis on Risk Management, and Western State University to obtain his law degree. In 1982 he was promoted to sergeant and also admitted to the California State Bar and immediately opened his law offices in Los Angeles.

Please indicate the scenarios where a vehicle pursuit is deemed permissible by selecting the appropriate options below
Dash camera footage shows Officer Brandon Gross being dragged nearly 40 yards while trying to stop a fleeing DUI suspect
Ralph Bouzy, who faces three counts of attempted murder, will be committed to a secure facility for mental health treatment
Retired Lt. Dan Marcou was sitting at a picnic table eating a chili dog with his grandkids when a lone officer started pursuing a suspect on foot; the officer radioed for assistance, but Marcou ran to help