In the emergency management sector there is an intense interest in learning lessons from past events, particularly catastrophic events.  In a survey we did of chief officers of Australia’s fire and emergency services, one chief officer said, of after action learning:

There’s a learning there.  There’s space for improvement.  There’s space for change.  There’s space for all of that.  But is there space for blame?  No.  I think fundamentally where we continue to walk down the road of, it shouldn’t have happened, what went wrong, who’s to blame… when something goes wrong there’s two pathways; blame or opportunity to learn and improve.  Which path do we choose to take?  We keep stepping on the blame path.

When I speak to emergency service responders they are anxious about being held to account both in court and in the court of public opinion, for actions made and decisions taken in an information poor and highly volatile situation.  One reaction the community often has is to demand the ‘head’ of the agency, thereby denying that person the opportunity to learn from the experience.    Those concerns are real, so it is very disappointing to read the article in today’s Canberra Times ‘’Deep concerns’ voiced over new ESA head’.

The story relates to the appointment of Tony Graham as acting head of the ACT’s Emergency Services Authority.  Mr Graham, currently Chief Officer of ACT SES had been involved in the response to the Canberra 2003 fires and had been the subject of criticism in by the ACT Coroner in the post fire inquiry (see  The validity of those proceedings were contested (see R v Coroner Maria Doogan; ex parte Peter Lucas-Smith and Ors [2005] ACTSC 74) as was the question of whether or not Coroner Doogan’s findings were justified by the evidence (see Lucas-Smith & Ors v Coroner’s Court of the ACT & Ors [2009] ACTSC 40).  Generally speaking the Coroner’s view of her jurisdiction and the findings she should make were upheld.

But even if we accept the validity of the Coroner’s findings, the reaction of the fire brigades union is disappointing.  According to the Canberra Times the support that Mr Graham has received from the ACT Government is not shared by the fire fighters’ union:

The Canberra Times has received a leaked email from a veteran of the 2003 fires, which warns firefighters across the ACT hold concerns over the appointment.

The firefighter, who wishes to remain anonymous, said he was offended on a personal and professional level by the change.

“Approaching the ten year anniversary of the worst disaster Canberra has experienced, one of the men responsible for the outcome of the disaster has been handed the reins,” the firefighter wrote.

“At the risk of sounding melodramatic, I was almost killed during the 2003 firestorm, and I wish never again to be involved in incidents under the control or influence of Tony Graham,” he wrote.

Mr Graham will also be able to exercise strong new powers, introduced in August, to make key decisions surrounding whether volunteers or professional firefighters take the lead role in fighting each bushfire as it happens.

The United Firefighters Union says it has been contacted by many firefighters warning they are uneasy with the appointment.

UFU secretary David Livingstone said they have been told “loudly and clearly” by members that they don’t want Mr Graham in the top job.

“The UFU shares the concerns that our members have expressed, and we agree with them that in this case, the history speaks for itself,” Mr Livingstone said.

The problem with that attitude, and that ‘history speaks for itself’ allows for no learning.  The Coroner may have found that in 2003 “Mr Graham displayed a lack of judgment by failing to recognise the limitations of his skills and experience in dealing with major fire events” and that his superior officers failed to ”see that Mr Graham was limited in “skills and experience”, but that was 10 years ago.   If we believe that we can learn by experience, Mr Graham is no longer limited in skills and experience in part because of this experience with the 2003 Canberra fires.  Ten years on, and with his experience in the ESA he is a different person just as the fire agencies are different, in part because of that particular event.

If we are going to insist that ‘history speaks for itself’ then no-one is allowed to learn from experience.  One event should not define one’s career for ever.  Presumably the fire fighters expressing their concern at Mr Graham’s appointment do not want to see their career end if ever their judgement is questioned.  Should a leading fire fighter have no opportunity for promotion because they make a poor judgement on a fire ground, or does that sort of experience make them a better officer, or in this case chief officer?

The emergency services and their staff, and research we are conducting at the ANU, is looking for ways to develop a no blame learning culture, such as that adopted in the aviation industry and increasingly in medicine with the development of ‘open disclosure’ standards, where mistakes are admitted and remedial action taken.  ‘Errors’ are not usually just the error of an individual but of the system in which they work, including, if we accept the Coroner’s findings, in this case where according to Coroner Doogan, the senior officers failed to appropriately understand the limitations of a more junior officer.   It will be hard to argue for a no blame learning culture if emergency services personal are just as willing to enter the ‘blame game’ as the public and the media appear to be.

DISCLAIMER: Mr Graham is currently the Chief Officer of the ACT State Emergency Service.  I am volunteer member of that Service but I note that, in that capacity, I have had no personal dealings with Mr Graham.

Michael Eburn

31 October 2012.