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 http://www.courts.act.gov.au/magistrates/page/view/596). 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.
Australian Emergency Law 
A very good article Michael. It is a very good point about ourselves trying to build a no blame culture and being the first to enter the blame game. Look at the facts. It is dissapopinting when people are happy to be so critical and stay anonymous. If you cant say it publicly and stand by it, dont say it publicly. We may well end up in a situation where no one will take the lead if we continue to criticise and not learn. Who will want the job in the future. After 10 years you think we would have started to move forward. If the person who commneted about having such a traumatic expereince, I do hope they are recieving support and hlep themsleves, so they are able tomove forward also.
A great and provocative article, and no doubt for those honest enough to reflect, a test of their own careers, ambitions and ability to learn. The lessons learned paradigm challenges all ES managers to lay aside the blame culture and lead in changing and shaping the future of our services’ capability. As in the comment above, I too hope the injured firefighter is seeking ongoing assistance in support.
At times individuals can be in a position where they are under qualified and out of their depth. When this occurs people should learn from their mistakes. It is difficult to learn from mistakes when at a coroner’s inquest the individual suffers from loss of memory on 358 occasions (see p51 of the inquest http://www.courts.act.gov.au/resources/attachments/The_Canberra_Firestorm_(VOL_I).pdf). One of the major purposes of a coronial inquest is to “to determine what happened and why, to try and make recommendations to avoid future deaths and fires” (see https://emergencylaw.files.wordpress.com/2009/06/why-being-called-before-the-coroner-is-worse-than-being-sued1.pdf) Not all lessons learnt are good ones. Mr Graham may have learnt that you do not have the take responsibility for your mistakes and that if you avoid responsibility you can rise to the position of acting commissioner.
Coroner’s are to ‘to determine what happened and why, to try and make recommendations to avoid future deaths and fires’ but they do, as the 2003 inquest did, run the risk of dissolving into an adversarial process rather than a fact finding mission. The Supreme Court may have found that Coroner Doogan’s findings were open on the evidence and the she understood her jurisdiction, but it does not follow that her findings were actually correct and on one view at least, the cause of the Canberra fires was a lighting strike, and laying blame, in this case, on four individuals is unhelpful. The Coroner’s court cannot make binding decisions, but the Supreme Court can and we now know that this Court is no longer being asked to rule on issues relating to the ACTs response in 2003, as the parties have settled that case with, if the Canberra Times is correct, a verdict in favour of the ACT and the Territory’s officials.
‘Mr Graham may have learnt that you do not have the take responsibility for your mistakes and that if you avoid responsibility you can rise to the position of acting commissioner’ or he, and other agency staff may have learned ‘if you don’t keep detailed, per minute records, you will get hammered by the Coroner’. If you think about cross examination and getting asked minute details about every event, it’s not so unreasonable to think that people won’t remember. I’m sure if I asked anyone if they could recall, verbatim, every conversation they had, or everything they did on a very busy, charged day, they too would not remember.
Cross examination is expected to test the evidence of the witness, it’s a gruelling process characterised by the right of the cross examiner to ask leading questions, that is questions that suggest the answer. Such questions are not permitted in examination in chief. Because they are leading questions, as a lawyer I used to tell my clients there are five answers to cross examination, they are:
1. Yes;
2. No;
3. I don’t know;
4. I don’t remember; or
5. I don’t understand the question.
If you are asked ‘So when this happened you said x isn’t that correct?’ it can be quite appropriate to say ‘I don’t remember’ rather than admit you said ‘x’ because something like that may have happened. The coroner was of course right to note what she called the corporate memory loss, but part of the problem with learning lessons is that these adversarial processes (even if they are not intended be adversarial) do restrict people’s ability to tell their story and as in this case, are used to set up the long running but ultimately unsuccessful civil litigation.
But even if you accept the coroner’s criticisms on their face, what’s the ‘unforgivable error’ and what does ‘accepting responsibility’ mean? And what responsibility does an individual member of a team, that’s part of an agency, that’s part of a government, that’s part of a community have? The ACT did not accept that either it or its staff were negligent in the response to those fires (hence they defended the litigation and challenged the coroners’ processes) so if the ACT government did not ‘accept responsibility’, believing that it and its staff acted reasonably in the circumstances (and reasonably does not mean ‘perfectly’ or ‘ideally’) what responsibility do you want an individual to ‘accept’? Do you expect him to parade in the street saying ‘it was all my fault’? I just don’t understand what is expected when there are calls for individuals to ‘accept responsibility’ or what that would look like. I note that during the Black Saturday fires there was public criticism that a fire officer who had been involved in the Boorabin fires of WA, where four truck drivers were killed, was still operating as part of an IMT. Again the government of the day stood by him and said that he should be allowed to continue. Fire fighting is a risky, life threatening business; if you are an IC at a hazard burn that gets away from you do you have to resign or end your career? Or sell your house to pay the damages?
Fire fighters are terrified of the coronial process, they don’t believe that the processes are capable of taking into account the complexity of the situations they face, and that these inquiries tend to look to blame an individual for outcomes that are the product of many decisions by many people (including decisions made long ago in areas of land use planning and resourcing) and the impact of uncontrollable, extreme natural events. If firefighters want their organisation to stand by them, to support them and to accept that sometimes sub-optimal decisions will be made, then they can also expect that senior officers will get the same benefit. If the government has confidence in Mr Graham then it is the government’s prerogative to appoint him as ESA Acting Commissioner, in the same way that if the ACT Fire Service has confidence in a fire fighter they can promote him or her even if, 10 years earlier, they were involved in an event that did not have optimal outcomes. If the UFU has concerns about the appointment it should relate to recent conduct, not conduct of 10 years ago and certainly not merely to the fact that a coroner made adverse findings. The fact that he was there in 2003 surely helps make him a better Acting Commissioner than getting someone who’s never been there. A person who never makes mistakes, never does anything.
Let me make my point very clear: I don’t personally know Mr Graham, I don’t know, other than what I’ve read in the Coroner’s findings and other public reviews of the 2003 fires, about what he did or did not do during that event. I don’t know if he’s a good choice for acting commissioner of ESA. My point is that it is disappointing, given the discussions I have with fire fighters about their concerns over adversarial inquiries and the risk of personal blame falling to them, that the UFU, and some ACT firefighters, are unwilling to accept this appointment on the basis of what happened 10 years ago and more importantly because of criticism by the coroner. If that is the precedent they want to live by then presumably they too are willing to keep, or lose, their jobs on the basis of the next court inquiry, regardless of whether or not their agency or their colleagues believe they did a good job in the circumstances or want to offer them opportunities to learn from the event.
Michael Eburn
I had nothing to do with the Canberra times article, my personal concern is not due to the events of 2003 or the coroners findings. They are due to Mr Grahams actions at the inquest. My only other problem with your article was that experience does not by default improve, for example a bad experience can lead to reluctant and untimely decision making in the future, just as other bad habits can be learnt.
Thank you for the clarification. My concern is that if we make decisions based either on the findings of the coroner (which relate to the date of the event) or the conduct at the inquiry (which naturally occurs some time later) then we don’t ‘allow’ people to learn. If you stand condemned by either there is no allowance that the experience has taught you something. I agree that experience does not necessarily lead to improvement, but we do generally believe we learn by experience. My desire would be that people are judged by what they have done after an event (in this case the 2003 fires and the inquest) not by the findings of that inquiry, because if you stand or fall by what the coroner said then you are condemned for all time, as the coroner’s report is fixed in time. But surely we want to allow people to learn the lessons both from the event and from the post event inquiry. The concerns raised in the Canberra Times article referred only to conduct during the 2003 fires. If a person’s conduct on that one day determines whether or not they can have a successful career, then we do not allow people to learn from their experience. If we do allow them to learn by their experience then the question, in this case, is about the persons capacity to do do the job now, not their capacity 10 years ago; but the Canberra Times article, and by inference, the UFU, made no case based on current performance. That, to me, is problematic, as it does not allow that people can and have learned by experience and does not allow that experience can be a useful teacher.
Fair point