#38 - The First Law Of Learning

Recap

In the last few posts (starting at Post #27) we’ve been exploring how four teams of firefighters survived the blow up of the Pagami Creek Fire up on the Boundary Waters (Minnesota) in 2011. It was a very Dynamic, Ambiguous, Risky, and Complex (DARC) day.

The firefighters survived due to their resilience and maneuvering.

They could only do that because of their operational learning.

And they only learned, because they were communicating.

Pyramid of Resilience

Finally we can close a loop from when I first introduced the Pyramid of Resilience. The base of the pyramid was still a mystery at that point (Post #35):

But thanks to the excavation we did together over the last few weeks on our expedition, we can finally identify the base of the pyramid. It’s Communication. Ultimately that’s the foundation for winning in the DARC.

Mayhew’s First Law Of Learning

This brings us to the First Law of Learning:

Operational Learning requires communication.

And the corollary to that law is also true:

No communication —> No learning.

To put that informally, here’s a little mantra:

If you can’t talk about it, you can’t learn from it.

Simple concept, right? Don’t let that fool you. These little sayings are profound and useful, and they can help you unlock learning. Here are a few examples of how they apply.

Application 1: The Challenge For Leaders

If you want to lead a learning effort after a close call or accident, part of your job is to figure out how to talk about it, and how to get others to talk about it in a meaningful way.

After tragedy, it’s pretty common that people start hunting for someone to blame. But the true villains are the thousand little factors that derail meaningful discussion. I mean those emotional, cultural, bureaucratic, legal and political forces that get in the way. If we can’t talk, we can’t learn, and therefore others are condemned to repeat the accident.

The challenge, then, for leaders is to overcome the myriad forces that stifle meaningful communication.

A Model: Alan Brunacini

Alan Brunacini’s response to the death of Bret Tarver is a model for this.

In 2001, Phoenix FD responded to a fire at the Southwest Supermarket. While inside, Firefighter Bret Tarver became disoriented and ran out of air. Other firefighters found him and pulled him from the building. They got him out, but it was with great difficulty and not in time for him to survive.

After the fire, Phoenix Fire Chief Alan Brunacini kept the building from being demolished until every firefighter from the Phoenix Valley had an opportunity to do a walk-through of the site. At that time, this was unusual. Brunacini’s emphasis on learning was a huge shift in fire department culture.

For the investigation, Brunacini formed multiple work groups to examine different aspects of the incident and what it meant for the fire department. All members of the department were invited to participate. These groups created lessons learned and recommendations. The department also conducted dozens of Mayday Drills. The purpose was first, to find out how long it takes to pull a downed firefighter to safety. Then, to find the most efficient way to do it. This was a novel approach; firefighter extraction procedures had never been studied like this before. They didn’t want Firefighter Tarver’s tragedy to be repeated.

The department released their investigation report a year after the incident. It included 198 policy changes for Phoenix Fire — many of which were also adopted by neighboring agencies. Phoenix built the world-renowned Command Training Center, where officers could run through and learn from simulations.

Brunacini recognized that the tragedy was not only a technical issue. It was also a social issue. He believed the department needed not only to repair problems, but also to recover. The investigation was only a start. Learning would require active, ongoing leadership. He planned and funded a five-year “recovery process.” He created a position to manage this process, and delegated the responsibility and resources.

This story illustrates the First Law of Learning. You see it within the investigation, and in the followup to the investigation, and in the relationships with neighboring departments. Again and again we see: People talked about the accident, so people learned from it.

It was a virtuous cycle.

And it went beyond the Phoenix Valley. Leaders from around the country were inspired to talk about accidents in their own departments, and share their lessons so the greater American Fire Service could learn from them.

A Model: Chino Valley Water Tender Rollover Investigation

For example, in 2008 a water tender from the Chino Valley Independent Fire District (Southern California) rolled over while responding to a fire, and it stopped just above a housing development. Department leaders decided to focus on learning, and did a groundbreaking investigation into the causes of the accident. They discovered there were know problems with the vehicle's design and training—problems known by the firefighters who drove it. But they didn’t talk the problems so the lessons didn’t get learned, until the accident.

Agency leaders decided it was time for a change. Leaders and firefighters talked openly during the investigation, then within the department after the investigation, and with other departments at conferences.

I heard their story from them at a conference in 2009, and they agreed to let me investigate their investigation. They summarized their approach around the principles “Learn, Share, Be Fair.” So, that’s what I titled my report (you can read it here).

I asked Chino Valley Fire Chief Kirk Summers why he took this approach on his department—why focus so much on learning when it was not the norm? He told me he attended one of Brunacini’s walk-throughs after the death of Bret Tarver, and was inspired to follow his example.

Communication and learning go hand in hand. And it’s a virtuous circle.

Application 2: Hard Truth For Investigators

Typically, when people like me think about Operational Learning, we think of formal processes—structured After Action Reviews (AARs), dialog sessions, and investigations. Those are great tools. I like teaching and writing about them.

But communication doesn’t have to be formal or structured to be effective. On the Pagami Creek Fire, the most meaningful Operational Learning came from firefighters talking to each other around a campfire or at a canoe landing.

This can be a bit of a blow to the egos of investigators and safety professionals. It means the greatest value of what we do is not in our learning protocols, our analytical horsepower, our data collection prowess, or our narrative talent. Obviously, those are important; they are absolutely part of the job. No question. But they are not the most important part of an investigation.

Ultimately, the real impact of an investigation is in how it leads to communication.

Because good communication is what leads to learning.

Which leads to resilience.

Which leads to success in the DARC.

Communication —> Learning —> Resilience —> Success

Application 3: Mission Of The American Fire Saga Blog

Focusing on the American Fire Service for a moment, the profession today is learning less from accidents than ever before in history. I think part of the reason is we don’t really know how to talk about accidents. The old views don’t work. The opposite of the old views haven’t served us well. So a lot of discussions never quite get productive.

The American Fire Saga blog gives you ideas, language, and tools you can use to have better discussions about accidents and close calls. That’s part of the mission here. Because the First Law of Learning suggests: If we can find better ways to talk about the past, we can learn better lessons for the future.

Back To The Boundary Waters

We’ve been exploring the concepts of communication, learning, resilience, and maneuvering, and how they fit together and help you succeed in the DARC.

In the Pagami Creek Fire example, we’ve only really explored these principles at the level of small teams working in the field.

But what about the level of Incident Management? We have not yet talked about that side of the Pagami Creek Fire. Turns out, the same principles apply there too. We will explore that in the next post.