Keynote speaker Tony Kern urges attendees to rethink human error & how it pertains to fireground decision-making
By Janelle Foskett

Complacency kills. It’s that simple.

In his Thursday morning keynote address, Complacency to Catastrophe, Dr. Tony Kern urged attendees to challenge the way they think about responsibility, accountability, the value of experience and, most importantly, human error, or more specifically, the big lie about human error (more on this later)—all as part of a “War on Error.”

As the CEO/senior partner of Convergent Performance, Kern knows a little something about these topics. Convergent Performance offers error-reduction programs to large organizations in the United States, and Kern himself has studied many incidents that resulted in fatalities, examining what went wrong in the decision-making process and where the human error factored in.

Kern acknowledged that his message was fitting for an audience of fire service professionals who work in highly dynamic environments where working to ensure that everyone goes home is the ultimate goal.

In his attempt to explain how smart people can make single-point errors that result in fatalities, Kern examined the role of complacency. He noted specific instances when complacency can creep in and lead to human error. The first instance involves the illusion that greater control comes automatically with greater experience. In other words, just because you’ve been on the job for a long time doesn’t mean you know everything or that you won’t make a mistake. In fact, Kern asserted that experience can work against you. You can do the same maneuver incorrectly hundreds of times and everything can turn out OK, so you “learn” this maneuver to be safe. But one day, the error will matter, and people could die.

To this, Kern added, “Things that never happened before happen all the time,” reminding the audience that an individual can’t learn from their own fatal error.

Kern also noted that complacency creeps in through routine non-compliance. Often, we see someone who is superior to us do something incorrectly and we then think we can do it incorrectly as well—even though we know it’s wrong. On this topic, Kern stressed that it’s important to remember that like the military, the fire service hires people who love extremes—and then we try to fit them into a box where policies and procedures actually matter. It can therefore be difficult to get people with this mindset to think about the important of compliance.

Another way complacency creeps in, Kern discussed, is through the normalization of deviance (NOD). Follow this chain of events: 1) an unexpected event occurs; 2) because nothing went wrong, no actions were taken; 3) this then becomes the new norm; and finally 4) an accident occurs and people wonder, “How did we allow this to happen?”

People get so used to not doing things correctly that it becomes the norm. In one example, Kern explained how an accident investigation revealed that the people involved suffered from a “disease of sloppiness”—something fire service personnel must consider when doing everything from something seemingly mundane, like paperwork, or something critical, like training. Everything matters, and you must do everything in your power to do the right thing—and to do it right.

Kern also addressed what he called the “big lie about human error.” That lie rests with the conventional wisdom that “to err is human,” a phrase we’ve all heard 1,000 times. Unfortunately, as Kern explained, this phrase provides a nice excuse for why things go wrong—an excuse that prevents people from learning the skill sets necessary to help them minimize opportunities for error.

But if we do take the time to learn the necessary skill sets, become accountable for our actions and reject the notion that “to err is human,” we give ourselves the ability to see trouble coming sooner. Trouble will always be on the horizon, but we increase the window of opportunity to fix the problem or, as Kern put it, we “move the point of detection back.”

Finally, Kern explained that many of us become stuck at the “good enough” level, held tightly by the “crushing grip of mediocrity.” Instead, we need to practice precision, and refine the necessary technical and non-technical skill sets every day. Further, we need to ask ourselves tough questions like, “Am I as disciplined as I should be?” “Am I as good as I should be?” Am I fully engaged?” “Are my skills getting better?” “Whose responsibility is it to make me better?” and “What kind of role model am I?”

Kern left attendees with a strong message for all fire service personnel: “You guys can lead the fight against human error. Teach the rest of the world how you’re going to do it!”

Janelle Foskett is the managing editor of FireRescue magazine.

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