#28 - Dominos and OMINODs
Dominos and ONIMODs
Dominos are a popular metaphor for explaining safety.1 The model starts by assuming a basically safe, stable environment. Then someone makes a bad decision or unsafe act, which leads another, creating a chain reaction that ultimately leads to an accident. Safety is a given, and you stay safe by avoiding unsafe acts. And you avoid unsafe acts through compliance. That’s where safety comes from in a domino story.
But now compare that to the story of Jess and Jamie’s survival, from my investigation of the Pagami Creek Fire in 2011 (see Post# 27). Where did their safety come from? They had to fight for it. As their environment grew dangerous and unstable, they responded. One decision after another turned out well. Along the way they avoided common, natural pitfalls that could have taken them to a different outcome. In the end, they maneuvered to safety.
Pagami was not a domino story. It was the opposite… it was an ONIMOD.
Study what you want
Accident investigators typically study failure. They spend considerable time, attention and resources trying to explain why things went wrong. It could make sense to do that, if the environment is basically Stable, Straightforward, Safe and Stable (4S).
A safety officer once told me the key to staying safe is to break the error chain—just grab the next domino before it falls. As he said that, he reached out calmly and suddenly snatched an imaginary domino off the table in front of us. “It’s that simple,” he said.
But when I started investigating firefighter accidents, I saw something different. I saw that fires were fundamentally Dynamic, Ambiguous, Risky, and Complex (DARC). Safety was not a given, you had to create it.
In every accident I investigated, I saw dozens of other accidents that could easily have happened, but didn’t. The reason they didn’t materialize was because firefighters took active measures to avert them. Safety was an active, ongoing, dynamic process. In other words, safety was something firefighters actually had to cause and sustain.
Why then, do we spend so much time analyzing errors, failures and accidents, but not success, survival and safety? If we want the latter, why not focus on them directly?
That question changed how I looked at accidents and how I wrote investigations. Of course, I still tried to understand the causal factors leading to accidents. But you will also notice in my investigations, I put a lot of effort into understanding how firefighters mitigated disaster, and actually avoided accidents.
Also, I learned to keep an eye out for ONIMODs.
What you can (and can’t) learn from ONIMODs
You might wonder how much you can really learn from a story like Jess and Jamie’s. You probably aren’t reading American Fire Saga to learn about canoes, or for tips on fighting fire in the Boundary Waters. Even if you do fight fire from a canoe, you will never re-live the exact scenario Jess and Jamie faced. Their story involved extreme conditions, unique circumstances, and a fair degree of chance.
So what does their story have to do with you?
Well, sooner or later you will face DARC times. The key to success in those times is resilient decision-making. By studying extreme cases like Jess and Jamie’s, new insights become clear that are not visible in routine examples.
That’s what Pagami is really about: it’s about resilient decision-making in a DARC environment.
In the next post, we will dive back into the Boundary Waters. We will go step by step through Jess and Jamie’s decisions. But we won’t just look at what they did, we will look at the context behind the actions, and how they made the decisions they did. I will also point out some of the pitfalls they avoided—pitfalls that could easily have brought them to a different end result. You will see—Jess and Jamie’s story is an excellent ONIMOD case study in resilient decision-making in a DARC environment.
Safety historian Carsten Busch sent a note letting me know this post excluded some of the nuances of the domino theory as it was originally expressed in the 1930s. He is right! And I’m glad he said something.
The intent of Post #28 is to respond to a popular metaphor I’ve heard fire safety people use, and distill it to its essence. Although I value the history of philosophy, that wasn’t the goal of this post.
If you want to know more about the domino theory, you will love Busch’s 2022 book on Herbert Heinrich: Preventing Industrial Accidents: Reappraising H. W. Heinrich — More than Triangles and Dominoes.
Heinrich was one of the earliest and most influential safety thinkers. He created or at least popularized the accident triangle and domino theory, and laid the foundations for behavior based safety (BBS). Busch did original research on Heinrich, illuminating the context of his ideas. Great stuff, even if you’re not a fan of triangles, dominoes, or BBS.
Thanks, Carsten.