Detroit Firefighter Not Thinking, Parks on Train Tracks
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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We had a similar incident affect our pipeline (4 of those StackTrain containers are mine), when a railroad worker left equipment on the tracks. Aside from initiating emergency-mode (hiccups in the pipe being the #1 problem with running lean [lowercase-“l”]), I was dumbstruck by the accident.
I mean, they were using the equipment to fix a derailment, and caused another derailment. I hadn’t thought of blaming the person, and how silly they were for working near the tracks – I wondered how the system could be so lax as to let it happen. You’d expect that’d be one of the most dangerous times for a railroad, with heightened senses & tight processes all around.
As for the firefighter… well, anyone driving a long vehicle should have special training regarding railroads. So, if they don’t already, this is something they can ‘legislate,’ if you will. It’s not telling each firefighter “OK, don’t park on train tracks, alright?” It’s highlighting common dangers relative to their environment & the equipment they use everyday. I don’t know if these trucks need Class A/B licenses, but there is extra training/rules for long vehicles around tracks.
Thanks, Brian – so you are saying do more education, don’t blame or punish the firefighter in this case?
Your story may be actual irony (as opposed to bad Alanis Morissette usage of the word ) — equipment for fixing a derailment CAUSING another derailment.
Interesting, Mark. “We’ll do some training” is a reactionary, knee-jerk reaction because obviously, you can’t train judgment. Our first reaction is to hang people for doing something stupid. But we all make errors in judgment, and sometimes even the best of us can become temporarily stupid. How I would handle this depends on the person. Are they complacent by nature, or was this just a gigantic goof done by an otherwise focused person? As a leader, I try to use the hammer only when the hammer is the right tool.
.-= Mike Sporer ´s last blog ..Q & A with Diane Ravitch =-.
“We’ll do some training” doesn’t seem such a bad remark to me.
It depends on what will be trained. I would think it needs to be part of the standard work to check the safety of the spot where you parked your fire-truck. After all, fire trucks might be parked in hazzardous situations all the time. The “Make a judgement about the safety of your parking-spot” could be part of a training and could be drilled. The first-aid tranings I took where quite clear about safety for yourself first. And it was part of the exercises.
So yes, training seems a good idea.
As for punishment, it depends. In genereal the person involved should be (made) aware of the fact that he made a serious mistake and behave in accordance with this. If so, punishement seems to add nothing. If not, the punishment should be so that the awareness would arise. Whether the person is aware, speaks from his or her actions in the future. Those would be the basis to judge whether to keep him or her in this position.
So no firing because of the mistake, but maybe for not learning from it.
It depends on their current training, Mark. If it doesn’t include rules of long-vehicle-and-railroad-tracks-etiquette, then I say it’s time for kaizen. If it does, then the firefighter in question may need some reprimand or re-training.
Fire the guy? No. But I probably wouldn’t have him driving any more fire trucks – take him out of the position of being able to make the same mistake again. His training to serve as an EMT/Firefighter certainly has some value for the public. Has he demonstrated poor judgment in other situations? If so, maybe this kind of work isn’t for him. Training doesn’t fix everything.
Mark – to play devils advocate, I’d *WANT* that guy driving the truck. Don’t you think he’s unlikely to make the same mistake twice?
You’re right that training doesn’t fix everything. Nor can you train for every possible permutation of what life throws at you. I don’t like the expression, but many people say “you can’t fix stupid.” I don’t think that fire truck driver was stupid… made a stupid decision, we can point out.
Interesting situation. I am curious how many of the people that were on the truck with the driver saw this as being a potential problem before it actually became a problem. This whole situtation could be partially attributable to a culture that scares people away from making suggestions/corrections even when the results could be horrible.
You’ve got a point, Mark. I don’t think he’d make the same mistake twice, but then again, I wouldn’t think he would have made that mistake even ONCE! So, part of me puts my HR hat on and thinks, “O.K., this happened once. If I continue to let him drive and he makes another very poor driving judgment resulting in significantly negative outcomes, then what?” First concern of course is for life and property, but a second time would also be a PR nightmare, and it would reflect directly upon my judgment that allowed it to happen. This would be the kind of story that makes the evening ABC World News… “Firetruck driver in Detroit, after wrecking one firetruck, wrecks a second…” It I were the manager that is a risk I wouldn’t be willing to take.
As a former HR Manager, and having managed people in other capacities, I learned that some people are not cut out for certain jobs – in lean or even nonlean cultures. Doesn’t mean we fire them – it means we find a place where they CAN be successful and work to provide an environment that ensures this.
I would break the accident into 2 parts:
1. It is a reflection on the firefighter’s ‘judgment’. As a firefighter, he will be asked to make a periodic judgments that have lives on the line. I would want to understand the factors that went into his making that superficially idiotic judgment. Was there urgency to get close to a fire? Was there no other point of proximity? Absent those considerations, I would be disposed to re-assign him to a role where judgment is not mission-critical. I would question whether additional training can instill the type of judgment that a firefighter needs to have – if they don’t already possess the maturity and judgment to know that a railway line is a dangerous place.
2. The fire department should have a robust policy for safe positioning of its vehicles during all operations. Is there a tall crane in the fire path? Is it in the fall path of a building or structure? Does it block a choke point for access/egress? Putting it on the railway line is a single instance of a larger systemic concern.
I have never seen a lone firefighter, they are usually in teams if they are driving the big truck. You would think one of the other firefighters would say “You may not want to park there”. Teams share accountibility to each other.
I agree with you Mark. The driver and whole station is proably on high alert to never do that again. The driver sholdn’t be punished since I am sure the lesson has been learned. Punishment should be used to correct behavior and that should not be an issue for this driver.
.-= Brian Buck ´s last blog ..Be Different =-.
Brian and Mark – I like the line of investigation that asks, “why didn’t anyone else say anything?” Good question.
Most of the responses given here involve jumping to countermeasures. The first thing I would do is find the root causes of why the incident occurred (probably using the 5 Whys process). As part of this, I would try to determine if there is a special cause or a common cause problem. Only after doing this would I decide on the countermeasure.
I’d find out whether there are any extenuating circumstances and also what kind of judgment he’d shown in previous cases. Unless there was an extenuating circumstance and his judgment record was clean, my inclination would be to either fire him or put him on work which was less safety-critical.
If you want to give people authority to make judgments, rather than being hemmed in by tight procedural rules, then you also have to hold them accountable.
Training is still the answer. However, I do not advocate push education. Rather, have the firefighter himself try to remember his thinking processes at the time. Have the individual be part of the training, telling his story and describing what might have happened if he had told himself, “Take 15 seconds to think about the unintended consequences”. Then build some scenarios that get attendees to address unexpected situations and think about their responses. This can help condition their minds, in advance, to consider all or at least most critical factors.
VoilÃ¡. Standard work for addressig unusual circumstances.
[…] Detroit Firefighter Not Thinking, Parks on Train Tracks […]
Not one statment so far has addressed the $600,000 mistake and who pays for that….the taxpayers of the community. The consequences of this huge mistake effects too many people, and a firefighters judgement has to be “spot on” at ALL times. He is darn lucky a life wasn’t lost with his stupidity. He needs to be fired….period! The next lack of judgement call WILL happen, it’s just a matter of time. Some people are cut out for emergent situations, but a lot are not!! He is in the wrong profession!