Interesting article here about the psychology of “near misses”. It’s human nature to think that a project is a great success even if total disaster was missed by a fraction.
I think there’s an interesting corollary here for EOD operations. Most countries have an investigation system for examining when there’s an incident that kills or injures an EOD operator or bomb disposal technician. But if the operator is “lucky” and escapes unscathed there’s often no such investigation… and as the article points out, the individuals involved tend to repeat their potentially disastrous behaviour. To quote from the link “People don’t learn from a near miss, they just say “it worked, lets do it again.”” Ok ,there are the occasional exceptions, but on a global basis I think the statement there is no investigation of near misses is true as generalisation.
I’m fascinated that the FAA has addressed their problems in the area of “near misses” by analyzing the issues and pre-emptively fixing them so that there has been an 83% drop in fatalities over the past decade.
So… how do we collect and analyse the “near miss” data from EOD operations? (And you know that generally the answer is that we don’t). I think partly there is a culture in bomb techs globally to avoid such activity and partly there are frankly weak oversight structures over most EOD units. That’s provocative I know but I stand by what I’m saying – argue me back if you wish.
One of the facts quoted in the article is that a risk analysis firm suggests that there are between 50 and 100 “near misses’ for every serious accident. Instinctively I wouldn’t be surprised if that stat applies equally to EOD operations.
Most incident investigations of EOD casualties work backwards – I think it’s time the community turned this on its head and EOD organizations get used to trying to spot the near miss. I don’t doubt that would require a huge cultural shift, and collection and analysis of a lot of data but I think it’s needed.
No arguments here Roger, the problem will be (and you have covered it already) that most nations will not have the the knowledge and experience to investigate this properly. When the incident goes past a near-miss and injury/damage or worse occurs, it is easy for any 'superior' regardless of knowledge and experience to demand a formal investigation. With a near miss, how does that superior know it has occurred or if he has been present, will he/she even recognise it as such?
This means the operator has to report himself. Easy in a H&SaW culture, where the bloke who nearly slips on a banana skin reports it, as he knows he has done nothing that people can make judgements upon. In any more complex situation, 'operators' will be reluctant to draw attention to themselves. We have all done things on operations which were 'safe', but didn't perhaps match regulations 100%.
A difficult one to enforce…
Whilst agreeing with the principle, in practice, as Kier notes, very difficult to enforce or even encourage. We tried to introduce a system from 11 Regt and PATO where Operators were encouraged to report their own near misses or indeed feedback any anecdotes from others confidentially. The number of responses was a nice round number!!
Some interesting parallels with ammo depot operations where we did introduce a scheme of compulsory reporting of near misses and even invited a respected senior speaker in from the petro chemical industry to explain why it was necessary and prove that it did prevent accidents – but only if the data was collected assiduously and analysed to predict trends etc.
Needless to say the funding, resources and if I'm honest, the will, to do this kind of fizzled out. A whole layer of bureaucracy would be needed and indeed the inevitable back room analysts second guessing what an operator should or shouldn't have done would surface.
One lesson identified but probably not learned, is that tiredness kills! Many operator casualties fall into to the 'can do' trap when they shouldn't; or, more often, the chain of command asks too much and is unable to distinguish war fighting risk from something altogether less noble!
Given the seeming (and understandable) lack of interest or enthusiasm for ‘official’ reporting I wonder if operatives could be taught to have a period of self-reflection, whereby if they thought anything was learned, they could then share without fear of repercussion.
I have heard many business presentations over the years where the sales team (or whatever) are encouraged to consider the ‘failures’ and learn for next time as well as celebrating the successes – indeed the idea being there is much more to be learned from the near miss than the hit!
Sorry for the tardiness to the discussion, but I wanted to throw this topic around a bit from some peers to gauge their feedback and perspectives as well.
I believe this should absolutely be part of the SOP within US military EOD units beyond the informal Team Leader brief to the Team Members of what happened.
However, as others pointed out above there is an issue with the military EOD personnel that is even more prevalent in the current environment of reductions: That the self evaluation would be used as an adverse action or performance measure for the EOD technician. Strict guidelines would have to be used at anything above the company level to allow for a protection of the tech in self reporting that would allow him/her a measure of safety in knowing that admitting to an action that was less than desirable would not be used by command against him. Intrinsically we know that all techs have bad days. Incidents sometimes seem to get out of hand, or hindsight brings a moment of clarity that we didn't have on the initial RSP analysis.
Given this, then a database or Lessons Learned would need to be established that would allow for collection and dissemination of these which would be invaluable to Team Leaders and subsequently used as part of the Team Leader Academy and certification training to help develop the scenarios and study materials. But again, there is a severe culture of 'higher command is out to get us' within the ranks that has to be overcome and many techs don't want to provide any information that would facilitate that.
On the civilian Bomb Squad side, it is a bit more difficult. As you know we have 460 plus bomb squads here in the US. They receive initial training and guidance from the FBI at HDS (taught by mostly Army techs), but after that there is no team leader certification and the standards for training are still in development. The reporting system in place (BATS) is still underutilized and by no means user friendly. Adding to their already mountain of paperwork would be the first challenge, so a system would have to be easy, and then the means to collect and dissiminate would be a challenge as well. However, the law enforcement personnel were more inclined to volunteer the near miss information vs. the military techs. The RLC system might be something we should look at as Andy stated above, as the US tends to look to our cousins overseas to judge if it is a good system or not.
The other advantage the civilian Bomb Squads have is that there is an association which can collect and disseminate such information in NBSCAB (National Bomb Squad Commanders Advisory Board).
The Thais I will discuss with when I go again this Autumn again to see if they have thought of this or not.
As usual a great point you brought up and keep them coming!
Roger, great stuff. I think egos have a very difficult time explaining luck. Pilots and nuclear power specialists take lessons learned very seriously…as they should. These lessons include near mishaps/accidents both fatal and injurious. The EOD community should learn a lot from these community approaches. We are conducting interviews on EOD Techs involved in serious accidents in Afghanistan. The video interviews are published on a product called IED IMPACT. It stands for injured military personnel assisting combat troops. Currently available in iPad app store and requires vetting for EOD qualified personnel, but this week, the web based version is due for release. It is a start. Lots of work left to be done….