Human performance improvement: How company officers can reduce mistakes on the fireground and at the station

It’s more than a safety program; it’s a mindset shift to help us learn from past mistakes to reduce risks and improve future performance


I’ve made mistakes. During almost every shift, something happens that I didn’t expect. Despite being a student of the fire service and spending ridiculous amounts of time trying to learn my trade, things still happen, and I still mess up.

Throughout the years, I’ve discovered there are two types of firefighters in this world. One type can humbly realize their mistakes and honestly address them with their crew (company officer and peers). The other type includes those who lie to themselves and others. They disregard their mistakes and hide them for fear of ridicule.

Human performance improvement is one way fire service leaders can address mistakes, no matter which type of person you’re dealing with.

The U.S. Department of Energy’s Human Performance Improvement Handbook defines it as
The U.S. Department of Energy’s Human Performance Improvement Handbook defines it as "a system that comprises a network of elements that work together to produce repeatable outcomes." (Photo/DOE)

What is human performance improvement?

I first learned about human performance improvement when speaking about near misses in the fire service at a conference for the electrical industry. As I listened to other speakers, I realized they had lumped together several fire service issues like situational awareness, decision-making and human factors analysis, and called it human performance. While some fire service professionals look at human performance from a fitness and wellness perspective (and that is part of it), the electrical industry has steered practically its entire discipline to analyze human performance in all facets.

The U.S. Department of Energy’s Human Performance Improvement Handbook defines it as "a system that comprises a network of elements that work together to produce repeatable outcomes." Essentially, it is how we do what we do. It's emergency operations. It’s fire prevention. It's training. Whether we check off a truck or are working on a complex multi-alarm fire, each of us has developed or been taught a system to accomplish our tasks. There are systems for wrapping a hydrant or setting up an aerial. These tasks have a network of elements that create a repeatable outcome.

Human performance is often looked at as a safety program. But it's really much more than that. Yes, if you improve human performance, you can reduce injuries, accidents and line-of-duty deaths – all crucial things. But if you improve human performance, you also improve how you operate on the fireground, on the drill field and in the firehouse.

Experts have identified five basic principles to improving human performance:

  1. Error is normal; even your best firefighter makes mistakes.
  2. Blame fixes nothing.
  3. Learning and improving are vital, and learning is deliberate.
  4. Context influences behavior and systems drive outcomes.
  5. How you respond to failure matters.

Mistakes: A critical learning tool

Human performance improvement includes behaviors, or observable acts, and results, or the outcomes of those behaviors. The concept involves how we do things and the results of those efforts. Events such as near misses, accidents or injuries are unwanted occurrences (or outcomes) when an observable act results in an unfortunate consequence. This is where mistakes come in.

Industries adept at human performance improvement use the diagram "Anatomy of an Event" when examining mistakes. The interesting thing is they go much deeper than simply identifying who made the mistake. They ask, "What caused the mistake?” This is much harder to answer.

The aviation and nuclear industries, for example, have pinpointed that most events involve more than mere individuals. They recognize that most of their events (injuries, accidents and near misses) stem from organizational issues, precursors to the error or flawed controls.

Since human performance is all about systems, when you make your system rely on the perfection (and more likely imperfection) of an individual, you WILL have an event at some point, if you haven’t already. As Sidney Dekker, human performance expert, says, "Workers are not the problem; they are the problem-solvers." If we allow those individuals who experience an event to be part of a solution to what caused their mistake, I believe we could improve our performance.

Todd Conklin, another human performance improvement expert, says, "The problem with being wrong is that before you know you were wrong, it feels exactly like being right."

Industries adept at human performance improvement use the diagram "Anatomy of an Event" when examining mistakes. The interesting thing is they go much deeper than simply identifying who made the mistake. They ask, "What caused the mistake?” This is much harder to answer.
Industries adept at human performance improvement use the diagram "Anatomy of an Event" when examining mistakes. The interesting thing is they go much deeper than simply identifying who made the mistake. They ask, "What caused the mistake?” This is much harder to answer. (Photo/DOE)

After a firefighter makes a mistake, we, as company officers, can be biased when considering the cause, as we already know the outcome of the firefighter's decision. The person who experiences the mistake, in most cases, did not foresee the outcome. Their decision-making process was based on the expectation of a different result. It's easy to look back at a decision-making tree and recognize areas where another decision could have averted the event. But the person who made the mistake did not have that advantage. That's where we, as company officers, come in.

Conklin believes that when a mistake is made, as a supervisor, you have two choices. You can either learn and improve from the mistake, or you can blame and punish. You can't do both. He uses the example that if you vociferously disapprove of your daughter’s first boyfriend, you likely won't be introduced to the second one.

As much as you might like to think so, your firefighters are not original. I'm almost sure that the mistake they made was made before by someone else somewhere in the fire service. If the error was made before and the officer blamed and punished, no one else obviously learned from it. However, if you take the same mistake, use it as a learning tool, everyone improves.

Accountability: It doesn’t include discipline

The method of blaming and punishing is probably eating away at you, begging the question, “What about accountability?”

When I talk about a mistake, I don't consider egregious actions, such as showing up to work drunk or consistently not making it to work on time, to be mistakes. Such actions are the result of poor decision-making and poor judgment, and company officers can address these situations in a straightforward manner. Your department no doubt spells out such transgressions in your policies and procedures manual. Rather, what I am referring to the results of unconscious decisions with unforeseen outcomes.

Accountability is paramount to learning and improving. However, somewhere along the way, we confused the meaning of the word accountability. According to Webster's Dictionary, it's "an obligation or willingness to accept responsibility or to account for one's actions." Nowhere in that definition is a disciplinary approach mentioned. Reprimand is not a part of the word accountability, but account sure is.

When someone makes a mistake and talks about it with the company officer their crew, or those on their shift or in their department, the events encourage discussion that provides learning and improvement. So, quit reprimanding people for making honest mistakes. They are human; it's going to happen.

Consequences: They still exist

While human performance improvement shifts us from a disciplinary approach to more of a learning process, consequences still exist. Whether there are litigious consequences, serious injuries, or even death, consequence is a factor in any error. The goal, however, is to provide preventive measures for future events. While our society is still very litigious, imagine how much more severe the consequence would be if there were opportunities to learn from similar events before lawyers discovered we failed to learn from the past.

National Institute for Occupational Safety and Health (NIOSH) reports are a great example of human performance in practice. While the consequence of an error (or a multitude of errors) led to a firefighter's death, we still take the opportunity for an unbiased third-party review that pushes educational material to prevent a similar event.

Human performance resources

Human performance improvement is not a new concept. There is a lot of information out there on this topic. I'd recommend looking up Dekker and his “Safety Differently” book and movie. Yes, I know I said this wasn't a safety thing, but check it out. He discusses how several industries greatly improved their operations by thinking differently about how mistakes are addressed.


Conklin also has some excellent material for the industry, along with Jake Mazulewicz.

Several folks in the fire service have also turned their attention to human performance. Chief Rich Gassaway of Situational Awareness Matters has been making the case for a while. Christopher Naum with BuildingsOnFire.com has some history with human performance improvement. The Leadership Under Fire team has been discussing the topic for nearly a decade. Also, Chief John Tippett with the National Fallen Firefighters Foundation and co-founder of the Firefighter Near Miss program, has related articles to check out.

Learn and improve

When firefighters make mistakes, it's frustrating for company officers. The challenge is the approach. Allow yourself to feel frustrated. Being upset is a natural reaction. But keep these emotions to yourselves or walk away to take a breather. Then allow your firefighters to learn and improve. It's not easy. Believe me, I've lost my cool at times. But that is something I own, I've discussed and hopefully now allow others to learn from.

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