Gordon Graham here! Thanks for taking the time to read my ramblings regarding the discipline of risk management. In my last article, I wrapped up my thoughts with a promise to talk about “learning management systems.”
During my years in graduate school, I explored the writings of the geniuses of risk management. One of my favorites was Dr. Archand Zeller. His words meant so much to me then (48 years ago) and they still do now. It is Dr. Zeller who developed Rule One of Risk Management, which I introduced you to in the last article: “The errors you are going to make can be predicted from the errors already made.” Or more simply stated, “There are no new ways to get in trouble.” To be fair, there are some “variations on a theme” – but it is the same stuff over and over and over again – in every occupation and profession.
Not to digress (I tend to do this quite a bit; I will readily admit my brain is all over the place), but not long ago I was doing a live program in Florida and during my presentation the cell phone of one of the attendees rang (I guess we can still use that expression – along with “dialing” a number, which no one has done for years). The fellow possessing that cell phone was suitably embarrassed. I stopped talking –and there is now dead silence in the room – and I pulled out my iPhone and pointed to it and said, “The cell phones on the West Coast have a #$&!-ing off-switch.” The group laughed and I then followed up with, “I love it when a cell phone goes off in class because it is completely inconsequential.”
No one needs counseling when a cell phone goes off in a classroom. No one dies, no one gets hurt. The only consequence is the person possessing the phone is a bit embarrassed. BUT if you are doing a high-risk warrant service tomorrow morning at 0300 HRS and you are part of a “stack” of cops quietly going down the hallway of some seedy motel with the goal of surprising a wanted armed felon and catching him in his REM sleep cycle – and a cell phone goes off – that can be very consequential. I can point out at least a dozen “lawful but awful” cop shootings caused by a cell phone ringing at the worst time possible, waking up the suspect and causing him to open fire on the cops, in turn forcing them to shoot him.
My point is this: The learning management system in the aviation world is much more robust than it is in the world of public safety.
Clearly a cell phone not being silenced pre-warrant service is an error. Most tactical teams will have some sort of checklist to make sure all electronic devices are silenced pre-raid. Going back to paragraph two above, there are no new ways to get in trouble, but there are some variations on a theme. While I never had a cell phone back when I was a cop in the 1970s (and for the young readers here, we did not have that technology then – seriously – there were no cell phones and you might have to google that if you think I am lying), many of us had a ring of keys hanging on our duty belt. If you were doing some “secret squirrel” stuff, you would either wrap the keys with a rubber band so they would not jangle and wake the suspect, or you would remove the keys and put them in your pants pocket so they would not make any noise. It is the same concept as silencing your cell phone.
Anyhow, back to the focus of this writing – the importance of “lessons learned.” Sadly, public safety is not great at learning from past mistakes. Walk up to any chief of police or sheriff and ask, “So what are the lessons learned from Ferguson, Missouri in 2014?” Trust me, you will get a blank stare. Since the “Ferguson incident” I have addressed the International Association of Chiefs of Police every year and I have addressed over 40 chiefs of police groups at their various state conferences, and I have addressed the National Sheriff’s Association regularly. When I pose that question to a group of 200 law enforcement executives (with my promise to them that I will not ask any questions to try to embarrass them) I will get a maximum of five hands going up – and most of the hands that go up are Black hands! So the only people who learned from Ferguson are Black law enforcement executives?
If you think I am picking on law enforcement executives, guess again! Walk up to any fire chief and ask, “So what are the lessons learned out of the Colerain Township fire that killed Captain Robin Broxterman and Firefighter Brian Schira in Ohio in 2008?” You will get a blank stare. For the last 10 years I have been fortunate to address the “Big Event” that FDIC puts on in Indianapolis and I have asked that question to fire chiefs. Most of the time no hands go up!
Let me move into school shootings. Walk up to anyone in the world of education and ask them what lessons were learned out of the Oxford, Michigan school shooting in 2021 – and you will get a blank stare. Final reports (after-action reports) are available but rarely accessed, and if accessed not fully read, and if read the knowledge is kept to the reader.
But walk up to any pilot – ANY PILOT – and mention the name Sullenberger – and that pilot will tell you exactly and precisely how to land a plane on the Hudson River. My point is this: The learning management system in the aviation world is much more robust than it is in the world of public safety.
I am closing in on my word count but let me wrap up this piece with some thoughts on my plan to “make the knowledge of one the knowledge of all” – to make sure what one person knows, everyone who is similarly situated will know. Here is my seven-step approach to properly address this issue:
- We need better investigations of public safety tragedies.
- We need to learn from these investigations.
- We need to learn from tragedies in other high-risk industries.
- We need to learn from close calls.
- We need to “bring back the best of the best” to share their accumulated knowledge.
- We need to capture information from “Level 3” employees before they separate.
- All the above need to be put into a system that will deliver job-specific information to each employee every day.
In my next article, I will start to cover this list in much greater detail. In the meantime, here is a closing thought. I have several different “legacy” projects in the works. I know my years left are decreasing annually so I am putting together some thoughts that will live beyond my years. One of my projects is entitled “Your Black Swan Is Someone Else’s Gray Rhino.” The title of that project includes two great books on my recommended reading list, The Black Swan by Nassim Nicholas Taleb and The Gray Rhino by Michelle Wucker. If you are seriously into this risk management stuff, read those two books.
My bottom line is simple: There are very few – if any – black swans in the world of public safety. Our tragedies are not sneaking up on us. They have happened before in other jurisdictions and in other states, but we are not learning. Just because it is new to you does not mean it is new to our profession.
Until our next visit, please work safely.
