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Unexpected, Unwanted

August 28, 2009

There’s a saying in safety and risk management that the only real accidents are those that are unpreventable.  A corollary to this observation is the notion that preventable events are predictable.

This does not, of course, mean we know when, where, or to whom they will happen, only that they will if we wait and watch long enough.  While this leaves plenty of uncertainty, it’s not enough to excuse reasonable precautions to prevent an event or prepare to minimize its consequences.  We can still control the consequences by focusing on what we will do when, not if, something happens.

In recent years, risk managers have observed that just as not every event that involves unwanted consequences can be considered unexpected, neither can every unexpected event be considered unwanted.  Indeed, some risks produce good outcomes.  If they didn’t no one would ever buy a lottery ticket, purchase stock in a company, get married, or have children.

On the fireground, we confront many uncertainties.  We often lack fundamental information about the location or extent of the fire, what’s burning, how the building is constructed, where people are located, and whether everyone got out before we arrived.  With all these unknowns, firefighters have little choice but to control what they can, starting with what strategy they pursue, which tactics they employ, who they assign, how they engage them, and what tools they use to get the job done.

Some of the first detailed field studies of expertise involving high-stakes decisions under conditions of time-pressure and ambiguity focused on firefighting.  These studies discovered that these myriad considerations in all their complexity become part and parcel of the incident commander’s situational awareness, rather than a set of discrete alternatives each considered separately according to their utility.  A good decision-maker, it turns out, knows implicitly whether the resources available meet the requirements of the job.

If they seem to, the process does not end with this decision.  (Despite the all the diverse considerations and uncertainties, decisions of this sort rarely present or resolve themselves as separate or discrete actions, but rather occur in a context that can be described as an amalgam or sequence of tightly coupled actions loosely aligned with a strategy that guides other such decisions and actions as they are undertaken simultaneously by similarly situated actors each of whom is separately engaged.)  Real risk management then requires constant attention to one’s assumptions and expectations: “What’s happening now, is it consistent with my assumptions, and what does it suggest about what I expect to happen next?”

A firefighter quickly learns that not deciding is itself a decision, and, more often than not, a bad one.  This is especially true when indecision results from the absence of intention rather than a lack of action.

Correct intentions depend upon clear expectations.  Sound expectations in turn depend upon continuous assessment of the situation and assumptions.  Avoiding unexpected and unwanted outcomes, whether on the fireground or anywhere else that involves uncertainty, ambiguity, complexity, competing objectives, or high-stakes, requires anticipation of and preparation for exactly these situations — the ones we would rather not think about much less acknowledge.  But like a car sliding on wet pavement, you have a better chance of avoiding a crash and getting where you wanted to go if you quickly recognize what’s happening and steer into the skid.

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