HARD LESSONS: Helping your team learn from failure. [Facilitation Guide]

In October 2015, two Kansas City firefighters, John Mesh and Larry Leggio, perished after a wall collapsed during a fire, crushing them.  Perhaps not surprisingly, after their deaths the Kansas City Fire Department put in place a policy related to “collapse zones” — areas where firefighters should not enter while fighting a fire, due to the likelihood of structural building collapse. 

You may be surprised to learn, however, that nearly two decades before these deaths the National Institute for Occupational Safety and Health encouraged all fire departments to issue such a policy.  In fact, it repeatedly released bulletins and reports on avoiding the risks of structural collapse, yet some 150 firefighters across the US have perished as a result of such collapses in the intervening years (Hendricks, Part I, 2016). 

Why?

Why, despite a decline in the overall number of structural fires and improvement in fire safety equipment, has the death rate of firefighters remained nearly the same for four decades (Hendricks, Part III, 2016)? That’s what two reporters, Mike Hendricks and Matt Campbell, at The Kansas City Star aimed to find out in their investigation into not only this fatal accident but hundreds of others that have taken place over the last twenty years. 

Tragic.  Confounding.  But, you may be wondering, what does this have to do with project, change, and implementation management?  What does this have to do with us?

Well, when I first heard about this reporting, I was immediately struck by the similarities between the dynamics that contributed to the deaths of these men and women, and the dynamics I see in organizations and teams that struggle, repeatedly, with failed or sub-optimal project, change, and implementation efforts.  To my ears, what these reporters were talking about was a failure to learn.

I am not suggesting that the impact of a failed project is in any way equivalent to that of the death of a firefighter, or anyone else. I am suggesting that whether we are part of a project team or a firefighting team, our ability or inability to learn and to act in ways that reflect our learning has consequences. 

I strongly advocate that teams invest time in learning about themselves, as a team, both when they succeed and when they fail.  Although it's currently fashionable to celebrate failure, my feeling is that such celebrations are appropriate only after everyone — individuals, teams, managers, leadership — has demonstrated real learning from their challenges.  As The Star's investigation into firefighter deaths indicates, talking and writing about failure is relatively easy. Changing as a result of what you've learned from failure — that's where the real work is. 

Especially during challenging times, team learning requires honest reflection to uncover if the team’s behaviors and habits may have been responsible, even if only in part, for their poor performance. However, it can be hard for team members to see their blind spots and bugaboos, individually and collectively. Facilitation of group learning under these circumstances can be tricky. You must be thoughtful and prepared, to avoid creating a session that feels like a "witch hunt," or a dreaded waste of time that glosses over the real issues. In these situations, I find that studying the experiences of others, like fire departments, can help open the doors of insight for both individuals and the team as a whole.  

How to help your team to learn from difficult experiences.

This article is the third in a series of case studies aimed at helping team leaders, managers and others to facilitate meaningful and productive learning conversations with their teams. (See also my post on common ethical failures using the Flint water crisis, and the importance of making end-user experience a priority in design, based on the US chip-card conversion.) 

Below I provide five scenarios gleaned from The Star’s investigation into firefighter deaths, which also highlight team dynamics that may lead to failure. Each scenario is presented along with a variety of questions that you can use to spur reflection and discussion on your team.

In sum, the five scenarios are:

  • Fighting fires without water.  This scenario outlines what happens when individuals and teams rush to act without proper tools, training or information, despite the knowledge that doing so will likely lead to poor outcomes. 
  • Policies are paper; this is real life.   This scenario describes how commitments or policies based on good practice will have limited effect unless they are well communicated, enforced and supported in a team's day-to-day work activities.  
  • “100 years of tradition, unimpeded by progress.”  This scenario highlights how tradition can be a double-edged sword.  Although often a source of strength, tradition can also challenge a team's ability to change and learn — potentially to their detriment. 
  • Heroes only need apply.  This scenario highlights the challenges that arise when a team or organizational culture reinforces or rewards rule-breaking behavior.  It also highlights the importance of developing a shared view of appropriate risk/reward trade-offs. 
  • If no one’s accountable, who's to blame? This scenario is designed for discussion among leaders or managers.  It reflects the challenges to consistent performance and clear accountability that can arise when leadership opts (explicitly or implicitly) to allow each team to define its own minimum standards of practice. 

To facilitate a team discussion, I'd suggest you select 1 - 2 themes that you feel are most relevant to your team's experience and use them as a focal point.  Importantly, be sure your discussion results in a team commitment to specific actions.  Once you identify how you’d like to change, or where you want to double-down on good practice, be sure to check-in periodically on progress related to your commitments. 

If you’d like more detailed suggestions, I’d be happy to send you a free, facilitation guide for this exercise. You can get it here

If you use this exercise with your team or have alternative suggestions that you feel might help others, please share your experiences with us in the comments section.  We will all benefit from your ideas. 


Fighting fires without water.

In a Kansas City Star investigation into two decades of firefighter deaths, reporters identified over two dozen firefighters who died because they rushed into a burning building either without a hose or without a “charged hose”. (A charged hose is one that is filled with water and ready to go.)  

In each of these cases, when the fire suddenly heated up, or the firefighter got lost due to low visibility caused by smoke, he/she did not have the one tool, a hose, needed to tamp down the heat or find her way out of the building. The Star reports that despite repeated advisories on the practice from national safety agencies, some fire departments still do not require firefighters, as part of their standard operating procedures, to enter a building only if a charged hose is available (Hendricks, Part I, 2016).

For reflection & discussion:

  • Put yourself in the firefighters' shoes — Why would you enter a burning building with no hose or no water?  Is the reward of doing so worth the risks involved? What advice would you give these firefighters?  Would that same advice ever apply to you or your own team? 
  • Have you or your team ever experienced the equivalent of purposefully “fighting a fire without water”?  What led you to do so? What was the result?  What would you do differently next time?
  • Are there practices, tools, knowledge, or skills that you should never skip, or do without as a team? Have you ever done so? What was the result? What practical actions can you take as individuals and as a team to ensure you don’t try to “fight fires without water?” 

 

Policies are paper; this is real life. 

An investigation into two decades of firefighter deaths by The Kansas City Star indicates that while some fire departments choose not to create policies aligned with best-known techniques, other departments have policies in place but fail to enforce them, sometimes with tragic consequences.  

A good example is “collapse zone” policies.  Collapse zones are designated areas where firefighters should not enter while fighting a fire because adjacent walls or other parts of the structure are at risk of falling. The Star reports that while some firefighters have been crushed and died when no collapse zones were put in place, others died even when they were.  Investigations found that in these cases, collapse zones were not communicated, clearly marked, or enforced during the firefighting (Hendricks, Part I, 2016).

We can imagine that fighting a fire is a fast-paced, unpredictable, and stressful venture where effective communication and enforcement may not be easy, but, for these same reasons, is vital.  

Tightening up operations at the fire scene to align with best practices can require not only a change in policy but also a shift in culture. One fire official described the shift in the environment that comes with upholding procedures put in place expressly to ensure the safety of firefighters. “It’s less comfortable being on the fire scene now than what is was.”  As the reporters note in their article:  “And by less comfortable, he means more disciplined, both among the command staff and average firefighters…”  (Hendricks, Part III, 2016). 

For reflection & discussion

  • What 1-2 things about the situation described above jumped out at you? What advice would you offer those involved to address the issues highlighted?  Would this same advice ever apply to you or your team — how?
  • Can you think of an instance when your team's good intentions or commitments did not turn into action? Why do you think that happened?  What practical actions can you take as individuals and as a team to ensure you understand and follow through on adopting improved practices, new policies or standard operating procedures? 

 

“100 years of tradition, unimpeded by progress.”*

A Kansas City Star investigation into firefighter deaths provides a myriad of examples illustrating how the mindset  “But, this is how we've always done it!” is alive and well in many fire departments. For instance, the reporters note that US fire departments still use helmets similar to those designed during the American Revolution, with a high peak at the front and long back (Hendricks, Part III, 2016).  Helmets used by fire departments in other developed nations more closely resemble motorcycle helmets. 

Another intriguing example offered by the reporters illustrates how elusive continuous learning can be. In the 1970s, most US fire departments changed their core firefighting tactic. Improved equipment allowed them to shift from primarily fighting fires by directing water on them from outside of buildings, to mainly fighting them from inside buildings.

However, many departments have been unwilling to change again when faced with evidence that it can be more effective to use an "old technique" —  dousing a burning building with water from the outside before any firefighters enter it.  Why? Doing so can buy them time to act, which is important because structural fires today burn faster and hotter today than they did decades ago, due to modern building materials (Hendricks, Part III, 2016). 

Although some are resisting, other fire departments are adopting or considering this “water first” technique.  How were they convinced?  Show and tell.  Researchers report that they won over fire departments by “sharing their research online and [and inviting] firefighters to witness live-burn experiments” (Hendricks, Part III, 2016). 

*The title of this section is a quote from the film Backdraft, mentioned in The Star article. (Hendricks, Part III, 2016). 

For reflection & discussion

  • What lessons or ideas from this scenario most interested you? Why? What do you think your team could learn from the experiences described? 
  • Identify a time when your team changed and adapted in the face of feedback or new information and one time when you didn’t.  What did you differently in each situation?  What are 1-2 lessons you should take away from the experience? 
  • What do you do as a team to stay informed of innovations that could benefit your work?  Is this sufficient? What are 1-2 things you commit to doing as a team to ensure you are continuously improving? 

 

Heroes only need apply. 

‘“I do not see another fireman and say, ‘Be safe!’ I say ‘Be BRAVE!!’ instead.”  

(As quoted in Hendricks, Part III, 2016)

As reported in The Kansas City Star investigation into over 200 firefighter deaths, the culture within fire departments as well as in US society in general, may be one of the reasons that, despite improvements in equipment and reductions in the overall number of fires, firefighter death rates have not budged in the last forty years (Hendricks, Part III, 2016).

Firefighters themselves have reported taking the job because they want to save lives, not worry about risks:  “It’s in our nature to want to save someone. If nothing goes wrong despite ignoring the rule, you’ll be praised for saving someone” (Hendricks, Part III, 2016). 

The significance of that last quote may be better understood with two pieces of additional context.

First, according to the reporting in The Star, only 11 of the hundreds of firefighter deaths they studied occurred during structural fires involving civilians. (Sadly, in all of these cases, the civilians also died, either prior to the arrival of the fire department, or along with the firefighters.) In fact, the vast majority of firefighters that died did so not while trying to save someone's life, but while trying to save an empty building (Hendricks, Part I, 2016).

Some argue it is impossible to know if a building is empty without entering it to investigate. While others advocate for more of a risk/reward perspective, such as that offered by a former fire chief and safety expert: 

“The building is probably doomed, and it was 30 minutes ago. Anybody who was in the building died before the door went up in the fire station. Now what we’re going to do is we’re going to commit suicide operating at it? That doesn’t make any sense.”  (Hendricks, Part I, 2016). 

Second, as noted above, fire departments and society regularly praise firefighters for breaking the rules, as long as things work out. In such scenarios “aggressive action” seems to pay off. However, more complicated are the cases in which such "aggressive action" leads to death or grievous injury.  In the case of firefighters who perish, we often praise them for their courage, even when it appears their deaths were avoidable, or the result of risky behavior. As one retired Fire Chief noted in The Star article: 

“We only have one eulogy and it’s a very heroic eulogy…the message to the survivors who are firefighters is this is an impressive, heroic kind of experience for us”  (Hendricks, Part III, 2016). 

Understandably, no one wants to criticize someone who gave his/her life in the service of others. However, if fire departments and firefighters fail to look critically at the factors that contributed to these deaths, how will they avoid them in the future?  How will they change the vexing reality described by one fire official:  “We know what kills firefighters in fires, and we know how to prevent it. But we keep having firefighters die" (Hendricks, Fatal Echoes, 2016). 

For reflection & discussion

  • What 1-2 things in the scenario described above jumped out at you? What advice would you offer to those involved? Could any of this advice also apply to you or your team? How? 
  • How does your team evaluate the tradeoffs between risks and rewards? Do you tend to be more risk-taking or risk averse?  Why?  Can you think of a case where you got the tradeoff right? When you got it wrong?  What specific factors/actions contributed to those different outcomes? 

 

If no one’s accountable, who’s to blame?**

The Kansas City Star recently published an investigation into the causes behind more than 200 firefighter deaths over the last twenty years.  In it, they offer a few facts about the regulatory environment in which fire departments currently operate.  Before we provided these facts, we'll ask you to take your best guess about them in the brief quiz below.  

Which of the following statements is true:

  1. Federal regulators establish mandatory, nationwide fire safety rules. 
  2. Firefighters are required to complete a minimum number of training hours. 
  3. Firefighters are required to complete annual physical exams.
  4. Firefighters' families have the option to take legal action in the event of a firefighter's death . 

If you guessed, “None of the above,” you are right.  

The Star reports that there is no federal agency that provides oversight of fire departments. There are also no mandatory federal regulations related to practices or equipment.  (Although such rules are currently under consideration at the federal level.)  According to The Star's reporting, there is also very little local or state regulation of fire departments (Hendricks, Part II, 2016).

Further, there are no national training standards for career or volunteer firefighters.  While the information provided by The Star on this topic is limited, what is provided indicates that training requirements can range significantly across departments — from no formal training at some volunteer departments to weekly sessions in other departments (Hendricks, Part II, 2016). What might be the consequence of this? 

The Star also reports that despite many factors that should contribute to falling death rates among firefighters — improved equipment, a greater focus on safety, fewer structural fires — the rates of death and injury among firefighters have not changed much over the last 40 years (Hendricks, Part III, 2016). Gaps in training have often been identified as at least part of the reason.

Finally, as many families of fallen firefighters have discovered, worker’s compensation laws in the US protect fire departments from lawsuits.  Even in cases where the fire department failed to uphold widely known safety standards, lawsuits against departments are rarely successful. As one lawyer quoted in the article noted:  “…the error must have been so far beyond the pale as to seem intentional” (Hendricks, Part II, 2016).

However, The Star also reports that successful lawsuits, or the pressure from threatened legal action, has led to some safety improvements in the departments involved. 

For reflection & discussion

There are evidence-based practices that have been shown to be effective in supporting program, change, and strategy implementation efforts.  There are also good practices, and related certifications, that support effective project management.  However, like the fire safety standards described above, in many organizations, they are adopted only at an individual or team's discretion.  Keeping that in mind, reflect and discuss the questions below.

  • What 1-2 things about the operational environment at US fire departments described above jumped out at you? What advice would you offer those involved?  Could this advice apply to you, your teams or your organization? How? 
  • As a leader, what is your perspective on the use of standards to guide practice on your project, change, and implementation teams?  How is that perspective reflected in the operations of the teams you manage or lead?  Do you feel any changes are needed - if so, what? 
  • Are there any consequences — positive or punitive — for teams related to the application (or failure to apply) practice standards related to their work? Provide specific examples.  Have consequences been consistent and appropriate?  Why/why not? 
  • Can you name any specific instances where failed or sub-optimal projects were caused, at least in part, by gaps in training or failure to use good practice?  What changes were made in light of those instances to shore up team practice?  If none, why?  What, if any, changes do you feel you should enact now? 

** Note:  This topic is best suited for a discussion amongst managers or leaders. 

 

REFERENCES

The material related to fire safety in this article is based on a series published in The Kansas City Star in December 2016.  In this investigation "the reporters analyzed hundreds of federal and state fatality investigative reports, five years’ worth of federal workplace safety inspection records and reams of meeting transcripts of an advisory board that recently proposed the first new federal safety regulations governing the fire service in decades" (Hendricks, Part III, 2016). 

"'Kansas City Star' Finds 'Preventable Mistakes' Lead To Firefighter Deaths." NPR. NPR, Dec. 2016.  Web. Jan. 2017 

Hendricks, Mike, and Matt Campbell. “Part I: In a tragic loop, firefighters continue to die from preventable mistakes." The Kansas City Star. Tony Berg, Dec. 2016. Web. 16 Jan. 2017.

Hendricks, Mike, and Matt Campbell. “Part II: Fire Fighters Protect Us, Who Protects them?" The Kansas City Star. Tony Berg, Dec. 2016. Web. 15 Jan. 2017.

Hendricks, Mike, and Matt Campbell. “Part III: Fire departments fight a culture that saves — and costs — lives." The Kansas City Star. Tony Berg, Dec. 2016. Web. Jan. 2017.

Hendricks, Mike, and Matt Campbell. "Fatal Echoes." Fatal Echoes. Tony Berg, Dec. 2016. Web. Jan. 2017.