We had a lot of spirited debate last week around the case of the pharmacist who was jailed after the tragic medical-mistake death of a two-year old girl (“A Pharmacist’s Jail Cell Interview – What Good Does Blame Do?“).
There are often no easy answers when something goes wrong. Do we blame and punish the individual? Do we look at the system? How do we respond as managers?
Here’s a case to discuss where nobody died – a fire truck was destroyed when it was parked on the tracks during a fire response call. You can see the article and a picture of the truck here – “Detroit firefighter ripped for parking on tracks after train hits fire truck“. So what do you do if you’re in charge?
From the story:
“The fire truck was parked right on the tracks,” said Willfrido Gutierrez, 27, whose Monte Carlo was struck by the tractor trailer. “I tried to get my wife and kid away from there and I heard a huge explosion.”
The truck, Ladder 13, was T-boned by the westbound train and crushed like an aluminum can and dragged a considerable distance before coming to rest on the tracks.
Clearly, this was the wrong decision on the firefighter’s part. People could have died, on the train or in the area. Note to those who ever think of driving around train crossing barriers — if a fire truck is “t-boned” badly by a train, what would happen to a regular car?
There’s often a lot of debate about the fine line between accountability and “no-blame culture” approaches. There’s certain a place and a time for accountability — such as when a person KNOWINGLY violates a safety rule and procedure and they knew harm was likely to result. But, there are exceptions to every rule — sometimes you knowingly violate a rule because another serious problem would occur if you didn’t violate the rule. That’s why responses to problems require judgement. For this reason, I’m not a fan of “zero tolerance” policies at schools, for example, that eliminate judgment and lead to kids being suspended for having an aspirin or a camping fork. Dr. Bob Wachter does a great job of writing about this balance in his blog post “Physician Accountability for Violation of Safety Rules: The Time For Excuses Has Passed“.
Back to the firefighter — did he violate a rule? There probably was no rule that said “Don’t park the fire engine on train tracks.” So, you probably can’t “write him up” for violating an explicit rule.
The fire chief said:
“It was a $600,000 truck,” Mack said. “We’re trained professionals. We should always be thinking. I don’t think the citizens of Detroit are pleased that he parked on the tracks.
“I’m very upset. This was a disservice to the citizens. It’s their fire truck — they paid for it.”
He’s right, especially that we should always be thinking. Toyota cleverly calls TPS the “Thinking Production System” to help emphasize that (nobody has claimed the DFD is implementing Lean, by the way).
The chief also said:
“I’m very upset,” said executive fire commissioner James Mack. “I’m going to make it known that this is not acceptable and we’ll do some training.”
A Detroit News reader made a great point — do you REALLY need to train people that parking a fire truck on the tracks is a bad idea? It seems that the publicity and the news about the situation would be training enough. Are they going to build that into “standardized work”? Are they going to brainstorm a list of 100 things you should NOT do?
I think we can’t proceduralize everything. We can’t document every little detail in life. We do have to, like it not, rely on judgment. And, judgment can be faulty in stressful situations – with a firetruck or in an emergency department.
So, my question to you the blog readers — what would you do? Would you fire the firefighter? Would you suspend him? For how long? What follow up would you recommend? What action would you take?
Where is the balance between blame and accountability on this one?
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