Do you learn from your experiences at a fire, or are there many important issues that don’t come to the fore, because we don’t systematically go through a process of learning to better our skills as firefighters?
The recent fires in Australia will see no less than five enquiries into these fires. However, let’s start at the station level; as a young firefighter I had a station officer who took the time when returning from a fire to talk about what we did well and what could be improved. In this non-threatening way we built our skills as firefighters and sometimes, if something arose that needed sharing or changing, it could be sent through the normal channels.
But we move outside our comfort zone when a formal debriefing takes place. Unfortunately, these normally happen when something goes wrong and everyone feels at risk of being criticized. Don’t get me wrong, these are very important learning experiences, but wouldn’t it be better if it was the norm and every fire had a debriefing that could concentrate on those things that went well, as well as those things that needed improving?
Now we take a massive jump to the types of inquiries that will engulf the Australian fire services over the next year – Royal Commissions, judicial hearings, parliamentary inquires and coronial inquests. You have moved from the comfort of your station/brigade to formal processes with five audiences, the inquirer, agencies, the public, politicians and the media.
The intention of all these groups is honourable but the process leaves a lot to be desired. I am of the view that placing people in witness boxes and having them cross-examined by Queen’s Counsel, then having them run the gamut of media people is not conducive to the best outcome.
Let’s start with terms of reference. In most cases those setting up the enquiry give a very broad range of things to look at, so as to cover every contingency. They even put the catch- all in at the end ‘any further issues that may come to the inquiries attention’. I submit that there are significantly different skills in identifying what needs improvement, what went well and how we learn, compared with identifying gross incompetence and liability. To have these two issues running at the same time does not make for a useful outcome. The separation of the learning experience from other side-issues such as political and/or media agendas would also be a step forward.
Terms of reference should be divided into two clear processes: one to look at the incident and how it was run, not by cross-examination (the adversarial British legal process) but by questioning (the French inquisitorial process); the second to look at gross incompetence and liability. Of course, there will be crossovers where issues are raised in one section that need referring to in the other, and this would be easy to manage if the two systems were run sequentially and overseen by different people. The skills to manage both sections are significantly different and require careful consideration. The separation will hopefully curb the media’s need for a public execution.
If the outcome of all these enquiries is to improve the way we protect the community we serve, then no matter which country you live in, we must expect that firefighters are human and make mistakes. If we cannot talk about those openly, we will not learn, and we will make the same mistake over and over again.
There is a good argument put forward by a good friend of mine, former Victorian State Coroner Graham Johnson. He was concerned that mistakes made during medical procedures were not being picked up because doctors were concerned about litigation. He argued that evidence heard during his inquests should not be available for litigation in other courts. I think he hit the nail on the head. To get to the truth of the matter so we can learn, other influences need to be put aside including political, media and supplementary legal action. Obviously criminal law would not be impeded.
In conclusion, you don’t get to the hub of a problem by adding inquiry after inquiry. A numbers game is not the answer. We need to select specialists to look at targeted learnings, not generalists to look at a shotgun approach.
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