Why a Different Approach to Incident Analysis is Needed: Prevention through learning (#2)
Error can be objectively determined in simple and some complicated systems. However, most wildland fire operations exhibit the characteristics of complex systems, they are adaptive and can change unpredictably. In complex systems the role of the human is to develop adaptations based on experience (heuristics). Simple process and procedural methods or approaches do not fully meet the needs of the fire community.
Currently, most reports or incident analyses focus on “facts” absent conditions. This concept relies on the belief that “facts” can be objectively determined without context. Human nature is considered to be adaptive and designed to optimize and avoid catastrophic outcome or loss. If people know the path they are on is leading to failure, they will naturally adjust the path to avoid adverse events. With this in mind, incidents are not the result of simple error rather they are the result of adaptations that fail. Understanding human limitations and environmental conditions is needed to place actions in context in order to learn from the event.
Prevention can come from ‘fixes’ applied to identified system deficiencies; however, the human contribution to prevention is often missed by this approach. The people facing the hazards of everyday work are, often overlooked, contributors to the creation of safety in the workplace. Therefore this process is directed toward maximizing the individual learning that emerges from incidents, accidents and everyday work by developing a deep understanding of the conditions that shape human action. A modern adult learning based approach will be introduced to demonstrate both the importance and the comparative ease with which this can be accomplished.
AFAC 2013*